Ergonomic assessment of the surgeon's physical workload during standard and robotic assisted laparoscopic procedures

BACKGROUND

Standard laparoscopy is responsible for musculoskeletal problems because of surgeons anti-ergonomic positions. Robot-assisted laparoscopy seems to reduce these musculoskeletal disorders thanks to the surgeons seated position. The objective of this study is to evaluate the muscular strain and cognitive stress induced by these two techniques during real operations conducted on the pig.

METHODS

Electromyographic activities, heart rate, physical and mental workloads (NASA Tlx and Borg CR-10) were recorded.

RESULTS

Physical workload and perception of the effort invested was significantly greater during the standard laparoscopies (p<0.05). Mental stress was however identical for the two techniques. In Standard Laparoscopic group, greater physical activity was found for trapezius and dorso-lumbar muscles, and significant appearance of fatigue of the trapezius muscles should also be noted. Finally, heart rate during standard laparoscopy was increased (92.1 ± 1.6 bpm vs 83.7 ± 1.8, p<0,01), confirming greater physical expenditure.

CONCLUSIONS

Robot-assisted laparoscopy is a less physically stressful surgical technique than standard laparoscopy.

Slope effect on pushing forces

In some occupations pushing forces are frequent when performed on horizontal ground and are standardized (ISO 2002). In special cases employees are obliged to grow container on slopes and the strains are poorly investigated. The objective of this work is to measure forces required to push garbage container on horizontal and inclined at 0, 4, 11 and 16 % grounds. Sudden and significant increases in heart rate reflect the possible risk of heart overload in long displacements. This study proposes realistic limits and provides a simple and protective tool for a group of employees without distinction of age or gender. These limits can even be reduced to a quasi-linear model where push 200 kg is the maximum for 0% slope and 60 kg for 10% slope.

Two interacting cylinders in cross flow

Cylindrical structures in a group are frequently seen on land and in the ocean. Mutual flow interaction between the structures makes the wake very excited or tranquil depending on the spacing between the structures. The excited wake-enhancing forces in some cases cause a catastrophic failure of the structures. This paper presents results of an experimental investigation of Strouhal number (St), time-mean, and fluctuating forces on, and flow structures around, two identical circular cylinders at stagger angle α = 0°-180° and gap-spacing ratio T/D=0.1-5, where T is the gap width between the cylinders, and D is the diameter of a cylinder. While forces were measured using a load cell, St was from spectral analysis of fluctuating pressures measured on the side surfaces of the cylinders. A flow visualization test was conducted to observe flow structures around the cylinders. Based on forces, St, and flow structures, 19 distinct flow categories in the ranges of α and T/D investigated are observed, including one quadristable flow, three kinds of tristable flows, and four kinds of bistable flows. The quadristable, tristable, and bistable flows ensue from instabilities of the gap flow, shear layers, vortices, separation bubbles, and wakes, engendering a strong jump or drop in forces and St of the cylinders. The two cylinders interact with each other in six different mechanisms, namely interaction between boundary layer and cylinder, shear layer or wake and cylinder, shear layer and shear layer, vortex and cylinder, vortex and shear layer, and vortex and vortex. While the interaction between vortex and cylinder results in a very high fluctuating drag, that between vortex and shear layer results in a high fluctuating lift. On the other hand, the interaction between shear layer or wake and cylinder weakens mean and fluctuating forces and flow unsteadiness. A mutual discussion of forces, St, and flow structures is presented in this paper.

Social disparities in musculoskeletal disorders and associated mental malaise: findings from a population-based survey in France

AIMS

Various types of musculoskeletal disorders (MSDs) have comorbid mental disorders, which may in turn have a negative influence on disease course and role impairment, but the contribution of social factors to this type of comorbidity is a much under-researched area. This study investigates whether there is a socially patterned association of MSDs with different dimensions of mental malaise.

METHODS

The sample included 3,368 economically active participants aged 18-64 years, randomly selected from the Lorraine region in north-eastern France. Information was provided through a post-mailed questionnaire on fatigue, sadness/depression (Duke questionnaire) and cognitive disability during the last eight days.

RESULTS

MSDs were significantly more prevalent in manual workers, clerks and other occupations than in upper and intermediate professionals, and similar occupational disparities were found for cognitive disability, fatigue and sadness/ depression. Stratifying the sample, we found the occupational disparities in cognitive disability to be much stronger among participants suffering from MSDs than among participants not suffering from MSDs, and the occupational disparities in fatigue and sadness/depression to be limited to the subsample of subjects suffering from MSDs.

CONCLUSIONS

The findings demonstrate that the association of MSDs with mental malaise is much stronger in the lower occupational groups than in the higher groups. Given that psychological factors are implicated in disease prognosis and in the development of disabilities, awareness of the social dimension of the association and treatment of the comorbid mental disorders could open a promising avenue for reducing social inequalities in disability related to MSDs.

Growth hormone receptor, insulin-like growth factor (IGF)-1, and IGF-binding protein-2 expression in the reproductive tissues of early postpartum dairy cows

The growth hormone/insulin-like growth factor (IGF) system plays a critical endocrine role controlling nutrient metabolism in dairy cattle. In liver, growth hormone receptor (GHR) and IGF-1 are dynamically regulated by lactation and energy balance. Less is known about the regulation of GHR, IGF-1, and IGF-binding protein mRNA in reproductive tissues (uterus, ovarian follicle, and corpus luteum). The objective was to determine expression patterns for GHR, IGF-1, and IGF-binding protein (IGFBP)-2 mRNA in the liver, uterus, dominant follicle, and corpus luteum in Holstein cows (n = 21) sampled at 3 times during early lactation. The first postpartum ovulation was induced with an injection of GnRH within 15 d of calving. Nine days after ovulation [23 +/- 1 d postpartum; 20 d in milk (DIM)], the liver, uterus, dominant follicle, and corpus luteum were biopsied. Prostaglandin F(2alpha) and GnRH were injected 7 and 9 d after each biopsy to synchronize the second (41 +/- 1 d postpartum; 40 DIM) and third (60 +/- 1 d postpartum; 60 DIM) tissue collections. Total RNA was isolated and used for mRNA analysis by real-time quantitative reverse transcription PCR. Liver had more GHR, IGF-1, and IGFBP-2 mRNA than the reproductive tissues that were tested. Gene expression for GHR, IGF-1, and IGFPB-2 within tissues did not change across the sampling interval (20 to 60 DIM). The only detected change in gene expression across days was for cyclophilin in uterus (increased after 20 DIM). Parity had an effect on gene expression for GHR in corpus luteum. Neither level of milk production nor body condition score affected the amount of GHR, IGF-1, or IGFBP-2 mRNA in the respective tissues. The repeatability of gene expression within a tissue was 0.25 to 0.5 for most genes. In most instances, expression of a single gene within a tissue was correlated with other genes in the same tissue but was not correlated with the same gene in a different tissue. We did not find evidence for major changes in gene expression within reproductive tissues in postpartum cows. Differences between cows (independent of their BCS and milk production) accounted for a major portion of the variation that we observed.

Uterine and hepatic gene expression in relation to days postpartum, estrus, and pregnancy in postpartum dairy cows

The somatotropic axis consisting of growth hormone, the growth hormone receptor (GHR) insulin-like growth factor (IGF)-I, and IGF binding proteins changes with the stage of lactation and nutrition of the cow and may be 1 mechanism through which lactation and nutrition affect the establishment of pregnancy. The objective of this study was to quantify GHR, IGF-I, and IGF binding protein-2 (IGFBP-2) mRNA in liver and uterine endometrial tissue at 4 stages of lactation (40, 80, 120, and 160 days in milk) and around the time of artificial insemination. Estrus was synchronized with GnRH and PGF2alpha, and cows were inseminated 12 h after estrus. Uterine biopsies were collected immediately before the second injection of PGF2alpha (before estrus), at the initiation of standing estrus, and 4 d after estrus. Liver biopsies were collected once on 4 d after estrus. The abundance of GHR, IGF-I, and IGFBP-2 mRNA in liver and uterus was determined by real-time quantitative PCR. The amount of liver IGF-I mRNA was positively correlated with plasma IGF-I concentrations. Cows that became pregnant after AI had more GHR and IGFBP-2 mRNA in their liver than cows that did not become pregnant. There was no effect of DIM or pregnancy status on abundance of uterine mRNA; however, uterine GHR and IGF-I mRNA was most abundant at estrus. In summary, cows at different stages of lactation or with different pregnancy statuses had similar quantities of uterine mRNA. In contrast, liver quantities of mRNA differed relative to pregnancy status. These data provide evidence that liver indices of metabolic state may be indicative of pregnancy success.

Comparison of progestin-based protocols to synchronize estrus and ovulation before fixed-time artificial insemination in postpartum beef cows1

This experiment was designed to compare pregnancy rates in postpartum beef cows resulting from fixed-time AI (FTAI) after treatment with 1 of 2 protocols to synchronize estrus and ovulation. Cross-bred, suckled beef cows (n = 650) at 4 locations (n = 210; n = 158; n = 88; and n = 194) were assigned within a location to 1 of 2 protocols within age group by days postpartum and BCS. Cows assigned to the melengestrol acetate (MGA) Select treatment (MGA Select; n = 327) were fed MGA (0.5 mg x head(-1) x d(-1)) for 14 d, GnRH (100 microg of Cystorelin i.m.) was injected on d 26, and prostaglandin F2alpha (PG; 25 mg of Lutalyse i.m.) was injected on d 33. Cows assigned to the CO-Synch + controlled internal drug release (CIDR) protocol (CO-Synch + CIDR; n = 323) were fed a carrier for 14 d, were injected with GnRH and equipped with an EAZI-BREED CIDR insert (1.38 g of progesterone, Pfizer Animal Health, New York, NY) 12 d after carrier removal, and PG (25 mg of Lutalyse i.m.) was injected and the CIDR were removed on d 33. Fixed-time AI was performed at 72 or 66 h after PG for the MGA Select or CO-Synch + CIDR groups, respectively. All cows were injected with GnRH (100 microg of Cystorelin i.m.) at the time of insemination. Blood samples were collected 8 and 1 d before the beginning of MGA or carrier to determine estrous cyclicity status of the cows (estrous cycling vs. anestrus) before treatment [progesterone > or = 0.5 ng/mL (MGA Select, 185/327, 57%; CO-Synch + CIDR, 177/323, 55%); P = 0.65]. There was no difference (P = 0.20) in pregnancy rate to FTAI between treatments (MGA Select, 201/327, 61%; CO-Synch + CIDR, 214/323, 66%). There was also no difference (P = 0.25) between treatments in final pregnancy rate at the end of the breeding period (MGA Select, 305/327, 93%; CO-Synch + CIDR, 308/323, 95%). These data indicate that pregnancy rates to FTAI were comparable after administration of the MGA Select or CO-Synch + CIDR protocols. Both protocols provide opportunities for beef producers to utilize AI and potentially eliminate the need to detect estrus.

Timed artificial insemination of two consecutive services in dairy cows using prostaglandin F2alpha and gonadotropin-releasing hormone

Timed artificial insemination (TAI) protocols use PGF(2alpha) and GnRH injections to synchronize ovulation. The objective was to evaluate the PGPG protocol (d 0, PGF(2alpha); d 3, GnRH; d 11, PGF(2alpha); d 13, GnRH and TAI) for first TAI and also examine methods for second TAI in nonpregnant cows. A factorial test of the first PGF(2alpha) and first GnRH injections within the PGPG protocol was performed (the last PGF(2alpha) and GnRH injections were deemed essential to the TAI). Lactating dairy cows (n = 804) in a commercial herd were assigned to 1 of 5 first-TAI treatments, which were PGPG, GPG (d 0, no treatment; d 3, GnRH; d 11, PGF(2alpha); d 13, GnRH and TAI), PPG (d 0, PGF(2alpha); d 3, no treatment; d 11, PGF(2alpha); d 13, GnRH and TAI), and PG (d 0, no treatment; d 3, no treatment; d 11, PGF(2alpha); d 13, GnRH and TAI); the Ovsynch protocol (GnRH, 7 d, PGF(2alpha), 2 d, GnRH and TAI) was the positive control. For resynchronization, cows received either GnRH or the control (no injection) on d 22 after TAI. Nonpregnant cows on d 28 were then treated with PGF(2alpha) on d 29, GnRH on d 31, and TAI [i.e., resynchronization treatments of ReGPG (received GnRH on d 22) and RePG (did not receive GnRH on d 22)]. Pregnancy rates for PGPG, GPG, PPG, PG, and Ovsynch were similar at d 28 after first TAI. Analyses of multiple explanatory factors by logistic regression detected an effect of uterine or ovarian abnormality on the d-28 pregnancy rate (normal more likely to be pregnant). Day-42 pregnancy rates were affected by uterine or ovarian abnormality (normal more likely to be pregnant), postpartum disease occurrence (healthy cows more likely to be pregnant), milk production, and days in milk. Treatment was not significant for the d-42 pregnancy rate. Effects of postpartum disease, milk production, and days in milk on the d-42 pregnancy rate were apparently manifested through their effects on embryonic loss between d 28 and 42 of pregnancy. High-producing cows that received TAI early postpartum were most likely to experience embryonic loss. Day-42 pregnancy rates after the resynchronization treatment were affected by an interaction of the first synchronization treatment with the resynchronization treatment. We concluded that although PGPG can be used for TAI, a simpler TAI protocol that includes the last 2 injections (PGF(2alpha), 2 d; GnRH and TAI) would be equally effective.

Comparison of physiological and subjective strains of two protective coveralls in two short physically simulated demanding tasks

A total of 15 physically active male students carried out a normalised task (T(N)) and a task of access by ladder and scaffolding (T(L)) in two impermeable protective coveralls and a reference sports wear to compare the physiological and subjective strains. Heart rate (HR) was recorded and sweat loss was checked. Subjective evaluations of comfort parameters, acceptable exposure durations and physical exhaustion were recorded at the end of the tasks. Results show that both protective clothing, compared to the sport wear, increase significantly HR, RPE and CR10 in both tasks. However the strains of both protective clothing are not significantly different except in sweat loss and cumbersomeness.

Comparison of physiological and subjective strain in workers wearing two different protective coveralls for asbestos abatement tasks

The aim of this study was to compare the physiological and subjective strain in workers wearing a disposable "Tyvek" (TYV) and a ventilated "Mururoa" (MUR) coverall in a real working situation. Eleven men performing normal abatement tasks volunteered to participate. Physiological measurements included oral temperature, heart rate and sweat loss. Subjective evaluations of clothing comfort, cooling, robustness, cumbersomness, acceptable exposure duration and physical exertion were carried out at the end of the task. The ventilated MUR reduced heat strain. Indeed, it allowed significantly higher sweat loss than TYV and showed a tendency to reduce the increase in oral temperature. Subjective ratings reveal that MUR was considered better than TYV in terms of clothing comfort, coolness and robustness. On the other hand, MUR is more cumbersome to wear. In this study, where workload and heat stress were moderate, there were few differences between the two coveralls in terms of physiological strains, but far more significant differences in the subjective ratings.

A twenty-year history of alveolar echinococcosis: analysis of a series of 117 patients from eastern France

OBJECTIVES

Alveolar echinococcosis of the liver is a very rare and severe parasitic disease due to the growth of the larva of Echinococcus multilocularis. The aim of this paper was to describe a 20-year study of the epidemiological, clinical and therapeutic aspects of alveolar echinococcosis in eastern France.

DESIGN

One hundred and seventeen consecutive cases, diagnosed and followed in our liver unit, were studied from 1972 to 1993.

METHODS

Data from 85 patients followed since 1983 (period B) were compared to data from a first series of 32 patients (period A) collected from 1972 to 1982; 1983 was chosen as the cut-off year because of the numerous changes that occurred in the diagnosis, follow-up and treatment of the disease at this time, in particular the introduction of parasitostatic benzimidazoles.

RESULTS

The results of patient follow-up were evaluated in December 1997. The cumulative prevalence was 2.5 per 100,000 persons in period A whereas it reached 6.6 per 100,000 in period B. The annual incidence in period B was 7.3 on average, compared with 2.7 in period A. Twenty-nine per cent of patients from period B were asymptomatic at the time of diagnosis compared with 10% in period A. This change was correlated with less advanced liver lesions, and was related to the extensive use of abdominal ultrasound, and from 1987, serological screening. Curative resections were performed in 24% of the cases in period B versus only 3% in period A. From 1986, liver transplantations were performed in eight patients from period A and 13 patients from period B. In period B, palliative surgery was frequently replaced by radiological non-operative procedures to treat abscesses and jaundice. From 1982, 73 patients received benzimidazoles for a period of time ranging from 4 to 138 months. Stabilization of the lesions was observed in two-thirds of the patients. Episodes of jaundice or digestive haemorrhage due to portal hypertension were 31.5 and 11 times less frequent respectively in patients from period B compared with period A. Actuarial survival at 5 years improved from 67% in period A to 88% in period B in patients of similar age.

CONCLUSIONS

Radical changes in the diagnosis and the management of alveolar echinococcosis have occurred during the last decade. Together they have contributed to an improvement in the status of the patients affected by this very severe parasitic disease.

Field study of subjective assessment of negative pressure half-masks. Influence of the work conditions on comfort and efficiency

The aim of this study was to assess the effects of work conditions on the acceptability and efficiency of respiratory protective devices (RPD). The subjective evaluation of comfort, protection, respiratory and visual constraint, and the acceptable duration of wear of six RPDs against dust was achieved by 30 workers during their actual work. Metabolic rate was evaluated for each worker, and dry and wet air temperatures measured in the work area. RPDs objective protection factor was measured during each of the 180 test periods. In the conditions of this study, the acceptable duration of wear was about 1 h. This duration and the comfort parameters were reduced when the air temperature increased. The younger workers and/or smokers were less sensitive to mask discomfort. Objective protection factors of the RPDs are reduced under warmer conditions, and when the metabolic rate is low. Finally, the results of this study also show the poor capacity of standardized leakage tests to assess the objective respiratory protection of workers in the field. Some hypotheses which can explain this fact are discussed.

Structural model of a cyclic dynorphin A analog bound to dodecylphosphocholine micelles by NMR and restrained molecular dynamics

The compound c[Cys5,11]dynorphin A-(1-11)-NH2, 1, is a cyclic dynorphin A analog that shows similar selectivity and potency at the kappa-opioid receptor when compared to the native form of the peptide in central nervous system assays. Previous molecular mechanics calculations have shown that the ring portion of the isoform that is trans about the Arg9-Pro10 omega bond contains either a beta-turn from residues Arg6 to Arg9 or an alpha-helical conformation. Our results from solution state NMR indicate that the compound exhibits cis-trans isomerism about the Arg9-Pro10 omega bond in both aqueous solution and when bound to dodecylphosphocholine micelles. Restrained molecular dynamics calculations show that the cis isoform of the peptide contains a type III beta-turn from residues Arg7 to Pro10. Similar calculations on the trans isoform show it to contain a beta-turn from residues Cys5 and Arg8. In this report we describe the generation of three-dimensional models from NMR data for the ring portions of both the cis and trans isoforms of 1 bound to dodecylphosphocholine micelles. Comparison with other dynorphin A structural information indicates that both the cis and trans isoforms of the peptide may be active as kappa-opioid agonists.

Affective, Continuance, and Normative Commitment to the Organization: An Examination of Construct Validity

Within the past few years, several studies have used the Affective, Continuance, and Normative Commitment Scales (Allen & Meyer, 1990; Meyer & Allen, 1984, 1991) to assess organizational commitment. The purpose of this paper is to review and evaluate the body of evidence relevant to the construct validity of these measures. Although some empirical questions remain at issue, the overall results strongly support the continued use of the scales in substantive research.

Effects of modifications of residues in position 3 of dynorphin A(1-11)-NH2 on kappa receptor selectivity and potency

Tyrosine1 and phenylalanine4 in dynorphin A (Dyn A) have been reported to be important residues for opioid agonist activity and for potency at kappa receptors. The glycine residues in the 2 and 3 positions of dynorphin A may affect the relative orientation of the aromatic rings in positions 1 and 4, but their flexibility precludes careful analysis. To examine these effects on dynorphin A, we previously have synthesized the linear analogues [D-Ala3]Dyn A(1-11)-NH2 (2) and [Ala3]Dyn A(1-11)-NH2 (3) and reported their biological activities. Analogues 2 and 3 displayed affinities for the central kappa opioid receptor (IC50 = 0.76 and 1.1 nM, respectively) similar to that of Dyn A(1-11)-NH2 (1) (IC50 = 0.58 nM) and greatly enhanced selectivities for kappa vs mu and kappa vs delta receptors (IC50 ratios of 350 and 1300 for 2, and 190 and 660 for 3, respectively). These results suggest that the structure and lipophilicity of the amino acid present in position 3 of Dyn A(1-11)-NH2 as well as the conformational changes they induce in the message sequence of dynorphin have important effects on potency and selectivity for kappa opioid receptors. To further investigate structure-activity relationships involving the residue at the 3 position of Dyn A(1-11)-NH2, a series of Dyn A analogues with aromatic, charged, and aliphatic side chain substitutions at the 3 position was designed, synthesized, and evaluated for their affinities for kappa, mu, and delta opioid receptors. It was found that analogues with lipophilic amino acids at the 3 position of Dyn A(1-11)-NH2 generally displayed higher affinity but similar selectivities for the kappa receptor than analogues with charged residues at the same position. It is suggested that the structural, configurational, and steric/lipophilic effects of amino acids at position 3 of Dyn A(1-11)-NH2 may play an important role in potency and selectivity for the kappa receptor.

Synthesis using a Fmoc-based strategy and biological activities of some reduced peptide bond pseudopeptide analogues of dynorphin A1

Eight analogues of Dyn A(1-11)-NH2 incorporating the enzymatically stable psi(CH2-NH) isosteric peptide bond replacement were synthesized and tested for binding affinity at the central opioid mu, delta, and kappa receptors in guinea pig brain (GPB) homogenates and for activity at the peripheral kappa (and mu) receptors in the guinea pig ileum (GPI). The peptidic analogues were synthesized by solid phase techniques using a Fmoc/tert-butyl strategy, and the psi(CH2-NH) bond, or reduced bond, was introduced via reductive alkylation of the N-terminal amino group of the growing peptide with a Fmoc-N(alpha)-protected amino aldehyde. The synthesis of Fmoc-N(alpha)-protected amino aldehydes also is described. Several other peptides have been previously synthesized incorporating this modification and showed for instance increased enzymatic stability and antagonist properties. Results obtained in the GPB show that modifications of the peptide bond in the address site (analogues 4-9) do not affect the binding at the kappa receptor and, with a few exceptions, at the mu and delta receptors. On the other hand, analogues 2 and 3, modified in the message segment of Dyn A(1-11)-NH2, show a decrease in binding affinity at all three receptors. In the GPI, the results are more varied as the influence of the peptide bond modification seems to be more important than in the GPB. Finally, selected analogues were tested with no indication for antagonist activity at the kappa peripheral receptor.

In vitro stability of some reduced peptide bond pseudopeptide analogues of dynorphin A

Eight analogues of DYN A(1-11)-NH2 incorporating the nonhydrolyzable psi [CH2-NH] peptide bond surrogate were tested for their in vitro enzymatic stability in mouse brain homogenates. Results show that the Leu(5)-Arg6 and to a lesser extent the Arg(7)-Ile8 and Ile(8)-Arg9 peptide bonds are the more susceptible to enzymatic cleavage in the native peptide. (Leu5 psi[CH(2)-NH]Arg6)DYN A(1-11)-NH2 exhibits an almost complete resistance to enzymatic cleavage with a half-life greater than 500 min in brain, compared to 42 min for the standard peptide, DYN A(1-11)-NH2.

Seroepidemiologic screening of Echinococcus multilocularis infection in a European area endemic for alveolar echinococcosis

In a serologic survey for Echinococcus multilocularis infection, we screened sera from 7,884 subjects from the Doubs Departement in France, an area endemic for alveolar echinococcosis (AE) of the liver. An enzyme-linked immunosorbent assay (ELISA) with a highly species-specific antigen (Em2) and an E. multilocularis crude antigen (Emc) was used for screening. An evaluation of the cost/benefit relationship of this screening, followed by therapeutic management of patients, was made and compared with the actual cost of the follow-up and treatment of the disease in symptomatic cases in this endemic area. Antibody reactions to Em2 and/or Emc made possible the detection of eight asymptomatic clinical cases (seroprevalence averaging 1/1,000), with typical lesions of active AE revealed by abdominal ultrasonography and computed tomography. All were seropositive using the Emc ELISA but two were seronegative using the Em2 ELISA. In five additional seropositive cases, the radiologic investigations revealed small calcified lesions similar to the lesions of abortive AE previously found in Alaska. The cost of this serologic screening program per screened subject and per diagnosed case averaged 50.00 French Francs (FF) (U.S. $8.60) and 60,000.00 FF (U.S. $10,909.00), respectively. The cost of diagnosis, follow-up and treatment of the patients was 5,086.00 FF (U.S. $929.00) per patient per month in the case of diseases diagnosed by the screening program and 7,086.00 FF (U.S. $1,288.00) per patient per month for patients with symptomatic AE. This survey indicates a high prevalence of AE in the target area; it confirms the long latency period of the larval growth in human AE and shows that abortive AE is present in Europe. The use of both the Emc and Em2 ELISAs seems to be better than using the Em2 ELISA alone. The cost of the hospitalization and treatment of the eight screened patients would appear to be relatively high. Even though two of them were asymptomatic, they had very severe forms of the disease. In fact, the total cost was much lower than the actual cost of the disease when diagnosed from clinical symptoms.

Design, synthesis, and biological properties of highly potent cyclic dynorphin A analogues. Analogues cyclized between positions 5 and 11

We have recently reported the synthesis of several cyclic disulfide bridge-containing peptide analogues of dynorphin A (Dyn A), which were conformationally constrained in the putative address segment of the opioid ligand. Several of these analogues, bridged between positions 5 and 11 of Dyn A1-11-NH2, exhibited unexpected selectivities for the kappa and mu receptors of the central over the peripheral nervous systems. In order to further investigate the conformational and topographical requirements for the residues in positions 5 and 11 of these analogues, we have synthesized a systematic series of Dyn A1-11-NH2 analogues incorporating the sulfydryl containing amino acids L- and D-Cys and L- and D-Pen in positions 5 and 11, thus producing 16 cyclic peptides. In addition, Dyn A1-11-NH2, [D-Leu5]Dyn A1-11-NH2, and [D-Lys11]Dyn A1-11-NH2 were synthesized as standards. Several of these cyclic analogues, especially c[Cys5,D-Cys11] Dyn A1-11-NH2, c[Cys5, L- or D-Pen11]Dyn A1-11-NH2, c[Pen5, L-Pen11]Dyn A1-11-NH2 and c[Pen5, L- or D-Cys11]Dyn A1-11-NH2, retained the same affinity and selectivity (vs the mu and delta receptors) as the parent compound Dyn A1-11-NH2 in the guinea pig brain (GPB). These same analogues and most others exhibited a much lower activity in the guinea pig ileum (GPI), thus leading to centrally vs peripherally selective peptides, but showed a different structure-activity relationship than found previously. In a wider scope, this series of analogues also provided new insights into which amino acids (and their configurations) may be used in positions 5 and 11 of Dyn A analogues for high potency and good selectivity at kappa opioid receptors. The results obtained in the GPB suggest that requirements for binding are not the same for the kappa, mu, or delta central receptors.

A comparison of operative approaches and parameters predictive of success in multilevel arterial occlusive disease

BACKGROUND

The correction of abnormal inflow alone in patients with multilevel arterial occlusive disease (MLAOD) may be inadequate to relieve limb-threatening ischemia. This study was undertaken to compare operative approaches and attempt to define preoperative parameters predictive of limb salvage in patients with MLAOD.

STUDY DESIGN

The outcome after revascularization for 194 patients with limb-threatening ischemia MLAOD was assessed retrospectively. One hundred fifty-one patients initially underwent an inflow operation alone. Based on whether or not these patients required an outflow operation within one year, they were divided into two groups: group 1, no outflow operation (121 patients, 121 limbs), and group 2, outflow operation required for continued ischemic symptoms (30 patients, 30 limbs). A separate group of forty-three patients (43 limbs) underwent synchronous inflow-outflow operations, or multilevel revascularization, as their initial operative procedure (group 3).

RESULTS

Perioperative complications and mortality rates did not differ between groups. Limb salvage rates were similar for groups 1 and 3, whereas in group 2, limb salvage rates were significantly reduced (p = 0.0184). Long-term limb salvage after an isolated inflow procedure was associated with lack of prior vascular reconstructions (p = 0.0002), the absence of tissue loss (p = 0.0019), and an infrageniculate angiographic runoff score of less than 6 (p = 0.054).

CONCLUSIONS

In patients with limb-threatening MLAOD, synchronous inflow-outflow operations can be performed with resultant morbidity and mortality rates comparable with inflow alone. After an inflow operation, the approach of "expectant management" may ultimately compromise limb salvage if a subsequent outflow operation is required.

The effects of goal difficulty on physiological arousal, cognition, and task performance

Two laboratory experiments with 117 undergraduate students were conducted to examine (a) the effect of assigned goal difficulty on arousal (self-report and heart rate), cognition (perceived norm, self-efficacy strength, and personal goal), and behavioral (task performance) measures and (b) the role of heart rate as a mediator of the goal-difficulty-performance relation. All Ss performed a task requiring cognitive and physical responses. Results of both experiments demonstrated that assigned goal difficulty affected heart rate, cognition, and task performance and that heart-rate change was positively related to the cognitive and behavioral measures. Regression analyses suggested that a cognitive-affective mechanism may mediate the goal-difficulty-performance relation. Discussion is focused on the theoretical and practical implications of integrating an arousal concept within goal-setting theory.

A nine-year experience with crossover femoro-femoro-popliteal sequential bypass

Multisegmental arterial occlusive disease may require a combined inflow and outflow procedure for optimal treatment of limb ischemia. Twenty-one patients with unilateral iliac artery stenosis or occlusion and ipsilateral superficial femoral artery occlusion underwent crossover femoro-femoro-popliteal sequential bypass during a 9-year period. Seventeen operations were for limb salvage. Patency rates were determined separately for each segment of the bypass. Primary patency rates for the femoro-femoral segment were 89%, 83%, and 57% at 1, 2, and 5 years, respectively. Primary patency rates for the femoro-popliteal segments were 68%, 62%, and 40% at 1, 2, and 5 years, respectively. Limb salvage rates were 100%, 90%, and 77% at 1, 2, and 5 years, respectively. This experience indicates that femoro-femoro-popliteal bypass is an effective treatment in selected patients with severe ischemia due to combined iliac artery and superficial femoral artery disease.

Autogenous vein graft repair of injured extremity arteries: early and late results with 134 consecutive patients

Autogenous vein tissue is recognized as the preferred material for extremity revascularizations that require the use of a conduit. However, the results after vascular repair of injured extremity arteries with autogenous vein interposition or bypass grafts have not been well defined. This study was done to determine both the early and late patency and limb salvage rates as well as the graft infection rate of autogenous vein repairs of injured extremity arteries. The records of 134 consecutive patients with acute extremity arterial injuries requiring repair with a reversed autogenous vein graft over a recent 5-year period were reviewed. Follow-up graft patency was defined by the presence of a palpable pulse and an extremity Doppler-derived pressure index of greater than or equal to 0.9 distal to the arterial repair. Cumulative patency was assessed by the life-table method. Acute graft thrombosis occurred in two patients, one of whom underwent successful graft thrombectomy. Four patients (3%) required extremity amputation: one patient with a thrombosed vein graft and three patients with patent vein grafts but nonsalvageable limbs as a result of myonecrosis (2) or osteomyelitis (1). No perioperative graft infections occurred. One hundred twenty-eight patients (97%) had an intact extremity and a patent vein graft at the time of hospital discharge. One hundred three patients (80%) were examined at 30 days, and all grafts were patent. Seventy-three patients (57%) were available for follow-up at intervals exceeding 6 months, and 40 patients (31%) were followed-up for periods exceeding 24 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Solution structure of salmon calcitonin

Salmon calcitonin, a 32-residue peptide with a 1-7 disulfide bridge, was synthesized by standard solid-phase techniques, and studied by CD and two-dimensional NMR experiments. The peptide was dissolved in pure trifluoroethanol (TFE) and in aqueous solutions containing various amounts of TFE. CD studies in pure TFE indicated the presence of an alpha-helical structure comprising 40% of the constituent amino acids. This was fully confirmed by nmr. A detailed analysis was performed with the peptide in a 9 : 1 deuterated TFE/H2O mixture. A total of 365 nuclear Overhauser enhancements (154 intraresidual, 112 sequential and 99 long range) were complied from the nuclear Overhauser enhancement spectroscopy spectra and used in the distance geometry calculations. The core of the peptide between residues 8 and 22 assumes an alpha-helix like structure. The Cys 1-Cys 7 ring is well defined and in close association with the helix, while the C-terminal decapeptide folds back toward the core, forming a loose loop.

2-Diazohistidinyl thyrotropin-releasing hormone (TRH): a photosensitive TRH analog

We have synthesized a new thyrotropin releasing hormone (TRH) analog, pGlu-2-diazo-His-Pro-NH2 5, which is a potential photoaffinity label for the TRH receptor. Its precursor, pGlu-2-amino-His-Pro-NH2 4, has been synthesized through successive coupling of a 2-aminohistidine derivative 1 with proline and pyroglutamic acid derivatives. Diazotization of the fully deprotected tripeptide 4 gave the photoactivatable TRH analog 5. Compounds 4 and 5 exhibit IC50 values of 2 and 8 microM respectively, to be compared to the 0.02 microM value for native TRH.

Cellular immunity in experimental Echinococcus multilocularis infection. I. Sequential and comparative study of specific in vivo delayed-type hypersensitivity against E. multilocularis antigens in resistant and sensitive mice

Species- or strain-related differences in receptivity of intermediate hosts to E. multilocularis larvae could be related to differences in specific cellular immune response of the host. In order to test this hypothesis, we assessed the delayed-type hypersensitivity (DTH) to E. multilocularis antigens (EmAg) in mice of three strains differing by their sensitivity (AKR and C57BL.6) or resistance (C57BL.10) to E. multilocularis infection. DTH was determined by measuring in vivo the foot-pad response 24 h after an EmAg antigenic challenge. The level of positive response was evaluated in immunized mice; however, a typical DTH response was only observed by immunizing mice with a strong adjuvant schedule. Course of DTH in the immunized mice was shown to be somewhat different in sensitive and resistant mice. The differences were much more marked in mice infected with proliferative E. multilocularis larvae. The levels of the footpad response was significantly higher in resistant mice, although the peak of the reaction was obtained later than in sensitive mice. DTH, expressed by the foot-pad response against EmAg, remained significant for the entire period of observation in sensitive as well as in resistant mice. There was no correlation between receptivity of the murine hosts and levels of specific antibodies against EmAg. These results suggest a relationship between resistance to E. multilocularis infection and intensity and/or course of DTH in mice. The resistance could be mediated by some particularities of the in situ cellular immune response in the periparasitic granuloma.

Cellular immunity in experimental Echinococcus multilocularis infection. II. Sequential and comparative phenotypic study of the periparasitic mononuclear cells in resistant and sensitive mice

Cellular immune responses have been shown to be associated with differential evolutions of E. multilocularis infection in intermediate hosts. A relationship between course of delayed-type hypersensitivity (DTH) against parasitic antigens and receptivity of murine strains has been demonstrated recently. The aim of this study was to correlate resistance and sensitivity to E. multilocularis infection with the phenotypic patterns of cells within the periparasitic granuloma. Evolution of the ratios, macrophages/T lymphocyte and Ly1/Ly2 T lymphocytes, was associated with the receptivity of the strains. Persistence of numerous L3T4 + T lymphocytes and low numbers of macrophages and Ly2 + T lymphocytes were observed in the 'resistant' C57BL.10 mice. Comparison of the results with course of the DTH against E. multilocularis antigens showed that the particular phenotypic pattern observed in resistant mice was associated with a particular profile of DTH after infection. These results and similar observations in human alveolar echinococcosis suggest that cell composition of the periparasitic granuloma might be of crucial importance in controlling the spontaneous development of E. multilocularis larvae in the intermediate host.

A rapid, accurate, noninvasive technique for diagnosing critical and subcritical stenoses in aortoiliac arteries

Accurate hemodynamic evaluation of the aortoiliac system for the purpose of determining the need for an inflow procedure currently requires invasive pressure measurements. This study was undertaken to evaluate a noninvasive technique with the aortofemoral transfer function. Twenty-eight human aortoiliac segments were studied with intraarterial pressure measurements, with and without papaverine injection, and by calculation of the Doppler-derived mean power frequency index obtained by digital signal processing of aortic and femoral spectra. The procedure is menu driven and can be performed by any duplex ultrasound technologist. This technique involves recording 20 aortic and 20 femoral Doppler signals, requiring less than 1 minute of data acquisition time. Intraarterial pressure measurements were used to classify arteries into the three following groups: (1) normal arteries, (2) arteries with subcritical stenoses, and (3) arteries with critical stenoses. The mean power frequency index of group 1 arteries (n = 7) was 0.63 +/- 0.04, of group 2 arteries (n = 6) was 0.46 +/- 0.02, and of group 3 arteries (n = 15) was 0.21 +/- 0.05. These mean power frequency index values were significantly different by analysis of variance (ANOVA) (p less than 0.0001). Each group could be differentiated from the other groups with a sensitivity of 0.83 to 1.00, a specificity of 1.00, and an accuracy of 0.92 to 1.00 compared to intraarterial pressure measurements, including papaverine testing. Measurement of the mean power frequency index is a rapid, noninvasive technique that diagnoses and quantifies aortoiliac stenoses with an accuracy similar to intraarterial pressure measurements.

Hollenhorst plaques: retinal manifestations and the role of carotid endarterectomy

The ocular examinations and hospital records of 64 patients with Hollenhorst plaques were retrospectively reviewed to document any associated visual defects and to determine if carotid endarterectomy prevented the occurrence of new plaques or symptoms. One hundred nine Hollenhorst plaques were seen in 75 eyes; 18 had multiple plaques simultaneously. Visual field defects were noted in 14 eyes, four of which corresponded to the location of Hollenhorst plaques. Twenty-eight carotid endarterectomies were performed ipsilateral to a Hollenhorst plaque: 24 patients had no symptoms; four patients developed new ipsilateral asymptomatic Hollenhorst plaques at 1 to 50 months after operation. Two late strokes occurred, one of which was ipsilateral to a new Hollenhorst plaque, during a mean follow-up of 50 months (range 8 to 102 months). Thirty-seven eyes with asymptomatic Hollenhorst plaques did not undergo ipsilateral operation. Two eyes developed new Hollenhorst plaques during a mean follow-up of 23 months (range 1 to 132 months). Eight eyes in patients with no symptoms had multiple Hollenhorst plaques, one of which was associated with a subsequent stroke. Of the 29 eyes with a single Hollenhorst plaque, one subsequently experienced an ipsilateral stroke, and another had a transient ischemic attack (1 and 3 years later, respectively). Visual field defects infrequently corresponded to locations of Hollenhorst plaques. The cerebral hemisphere ipsilateral to asymptomatic plaques had a slightly increased risk of subsequent transient ischemic attack or stroke compared to the contralateral side without Hollenhorst plaques. The number of simultaneous Hollenhorst plaques in the retinal circulation did not predict clinical outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Hollenhorst plaques: retinal manifestations and the role of carotid endarterectomy

The ocular examinations and hospital records of 64 patients with Hollenhorst plaques were retrospectively reviewed to document any associated visual defects and to determine if carotid endarterectomy prevented the occurrence of new plaques or symptoms. One hundred nine Hollenhorst plaques were seen in 75 eyes; 18 had multiple plaques simultaneously. Visual field defects were noted in 14 eyes, four of which corresponded to the location of Hollenhorst plaques. Twenty-eight carotid endarterectomies were performed ipsilateral to a Hollenhorst plaque: 24 patients had no symptoms; four patients developed new ipsilateral asymptomatic Hollenhorst plaques at 1 to 50 months after operation. Two late strokes occurred, one of which was ipsilateral to a new Hollenhorst plaque, during a mean follow-up of 50 months (range 8 to 102 months). Thirty-seven eyes with asymptomatic Hollenhorst plaques did not undergo ipsilateral operation. Two eyes developed new Hollenhorst plaques during a mean follow-up of 23 months (range 1 to 132 months). Eight eyes in patients with no symptoms had multiple Hollenhorst plaques, one of which was associated with a subsequent stroke. Of the 29 eyes with a single Hollenhorst plaque, one subsequently experienced an ipsilateral stroke, and another had a transient ischemic attack (1 and 3 years later, respectively). Visual field defects infrequently corresponded to locations of Hollenhorst plaques. The cerebral hemisphere ipsilateral to asymptomatic plaques had a slightly increased risk of subsequent transient ischemic attack or stroke compared to the contralateral side without Hollenhorst plaques. The number of simultaneous Hollenhorst plaques in the retinal circulation did not predict clinical outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

[Child aggression by dogs: a preliminary study of risk factors]

Dog bites in children, although a genuine problem, have as yet been little studied in France from the viewpoint of epidemiology. A detailed study of 184 bites leading to management in a rabies control centre provided preliminary data on individual characteristics and behaviors of the dogs and children, as well as on features of the environment (place and time) that seem to be specifically associated with dog attacks on children. Increased insight into these risk factors should prove useful for the preventive information of children, parents, and dog owners.

Lupus-like anticoagulants and lower extremity arterial occlusive disease

Lupus-like anticoagulants (LLA), lupus anticoagulant and/or anticardiolipin antibody, are increasingly recognized in association with venous and arterial thrombotic events. We recently reviewed our experience with patients undergoing revascularization for lower-limb ischemia who were found to have LLA. Nine patients had LLA based on a prolongation of the partial thromboplastin time or by anticardiolipin assay by an enzyme-linked immunosorbent assay system. The ages of the patients ranged from 23 to 57 years. There were seven (78%) men, six (67%) blacks, two (22%) diabetic patients, and three (33%) hypertensive patients. One patient had systemic lupus erythematosus. All patients except one were cigarette smokers. Four patients had concurrent regulatory protein abnormalities: three protein C deficiencies, one protein S deficiency, and one plasminogen deficiency. The nine patients had 10 lower-extremity arterial reconstructions with two postoperative failures within 30 days. Patients were anticoagulated with heparin or aspirin after all but one operation. Patients at risk were identified on the basis of age (less than 51 years), unexplained early graft thrombosis, or history of venous or arterial thrombotic events. This group of patients is believed to be at risk for early postoperative thrombosis. Postoperative anticoagulation after revascularization for patients with LLA may be beneficial.

Open transmetatarsal amputation in the treatment of severe foot infections

Severe forefoot infections may lead to limb loss, even if addressed aggressively. Infection or gangrene that compromises the plantar skin flap may preclude a standard transmetatarsal or midfoot amputation, thereby culminating in a below-knee amputation. We report a series of forefoot infections with loss of the distal plantar skin. Open or guillotine amputation at the mid-metatarsal level led to a high rate of healing and a durable stump, provided that the level of infection did not extend beyond the metatarsal heads. Wound closure was obtained by wound contracture alone or by use of partial-thickness skin grafting. Rehabilitation was dependable. The association of diabetes mellitus or gangrene did not adversely affect outcome. Open transmetatarsal amputation is a safe surgical option preferable to midfoot or below-knee amputation for the treatment of severe forefoot infection that does not extend proximally beyond the metatarsal heads.

The use of sartorius muscle rotation-transfer in the management of wound complications after infrainguinal vein bypass: a report of eight cases and description of the technique

Although rare, major wound breakdown after infrainguinal bypass resulting in vein graft exposure carries the risk of vein graft disruption with threat to both life and limb. The use of sartorius muscle rotation-transfer specifically in the management of exposed autogenous infrainguinal vein grafts has not been previously described. Eight patients were evaluated for major wound disruption resulting in graft exposure after infrainguinal vein bypass. Soft tissue coverage was provided in all eight cases by means of a distally based sartorius muscle rotation flap. There was no instance of postoperative death, graft thrombosis, secondary hemorrhage, or persistent infection. Late follow-up has shown continued satisfactory results. We conclude that effective soft tissue coverage and salvage of exposed infrainguinal vein bypass grafts can be accomplished in selected cases by means of sartorius muscle rotation-transfer.

The role of isolated profundaplasty for the treatment of rest pain

This study was undertaken to determine the efficacy and durability of profundaplasty and define preoperative factors predictive of success. The hospital charts, vascular laboratory data, and arteriograms of 20 patients having 21 isolated profundaplasties for ischemic rest pain between 1979 and 1987 were reviewed. Follow-up extended to 72 months (mean, 26 months). Early success was achieved in 12 extremities (57%) and life-table analysis showed continued success to six years in 11 extremities (55%). Of the multiple preoperative factors assessed, only a low-thigh/ankle gradient pressure index (TAGI) of less than 0.55 was predictive of success. Life-table analysis for limbs with a TAGI of less than 0.55 showed an 89% success rate at six years compared with only a 32% success rate for limbs with a TAGI of more than 0.55. Isolated profundaplasty for the treatment of ischemic rest pain can be an efficacious and durable procedure when patients are selected based on objective hemodynamic measurements.

Analysis of 18 recent cases of penetrating injuries to the common and internal carotid arteries

Penetrating injuries to the common and internal carotid artery carry the unique potential for irreversible neurologic damage, respiratory collapse, and exsanguination. This study analyzes a recent 4 year experience with 18 cases of penetrating injury to the carotid artery to identify the factors influencing surgical decision-making, perioperative complications, and mortality. Sixteen patients with acute respiratory distress required emergent airway intubation. Three patients in hemorrhagic shock were brought directly to the operating room; the remaining 15 underwent emergency carotid arteriography. Three patients with multiple intramediastinal vascular injuries exsanguinated on the operating table before hemorrhage could be controlled. There were no deaths or neurologic complications in the 14 surviving patients who had an operation on the carotid artery, including 2 patients treated by internal carotid artery ligation. Early control of the airway was the most common initial requirement in this group of patients. Judicious use of preoperative arteriography was thought to facilitate the operative approach in selected patients. A flexible surgical approach to the damaged carotid artery is essential based on the patient's hemodynamic status, degree of neurologic impairment, and nature and extent of arterial damage.

Risk factors affecting the natural history of intermittent claudication

To determine the prognostic significance of the level of arterial disease in claudicators, risk factors affecting the progression of intermittent claudication, including hemodynamic variables obtained from noninvasive vascular laboratory examinations, were assessed. We identified 378 patients with intermittent claudication by characteristic history and the presence of abnormal treadmill exercise examination results. Results of serial examinations were available for 195 of these patients, who had 310 claudicating limbs. Life-table analysis revealed that after eight years, 41% of these patients had progressed to critical ischemia, defined as rest pain or tissue loss, and 50% had died. Cox proportional hazards general linear regression analysis found that at a patient's first examination in the vascular laboratory, the ankle-brachial index and the decrease in ankle-brachial index after exercise were significantly associated with the subsequent development of critical ischemia. The level of disease at the initial examination in the vascular laboratory was not a significant risk factor for progression to critical ischemia and therefore should not be used as an indicator for or against operation in patients with intermittent claudication.

Long-term results of infragenicular bypasses with autogenous vein originating from the distal superficial femoral and popliteal arteries

Forty-nine bypasses originating from the distal superficial femoral artery or popliteal artery in 46 patients were reviewed to examine late patency, limb salvage, and factors leading to graft failure. Operations were performed because of tissue loss in 86%, rest pain in 12%, and limiting claudication in 2% of limbs. Proximal anastomosis was from the distal superficial femoral artery in 12% and the popliteal artery in 88%. Distal anastomosis was to the below-knee popliteal artery or proximal tibial vessels in 20% and the distal tibial vessels in 80%. Life-table analysis showed a primary patency rate of 83%, 62%, and 41%, at 1, 3, and 5 years, respectively. The rate of limb salvage at 6 years for all grafts was 69%. Cox proportional hazards analysis determined that stenosis of 20% or greater in the proximal superficial femoral artery before bypass was a significant risk factor for graft failure (p = 0.02) despite the presence of normal intra-arterial pressure at the site of the proximal anastomosis at the time of bypass. Long-term survival in these patients was low, with a 6-year survival rate of only 24%. Infragenicular bypasses originating from the distal superficial femoral artery or the popliteal artery can be performed with patency and limb salvage rates comparable to bypasses originating from the common femoral artery. These bypasses are more likely to fail when performed in the presence of a stenosis 20% or greater in the superficial femoral or popliteal artery proximal to the graft origin.

Subclavian and innominate artery trauma: a recent experience with nine patients

This report summarizes a recent 24-month experience with 9 patients who were treated for injuries to the innominate or subclavian arteries at a large urban hospital. All patients were male, age range was 17 to 47 years, and mean age was 29 years. The mechanism of injury included major arterial avulsions sustained during cancer operations at the base of the neck (2), blunt injuries secondary to motor vehicle accidents (2), stab wounds (1), and gunshot wounds (4). The vessels injured included the right subclavian artery (2), the innominate artery (1), and the left subclavian artery (6). Associated major venous injuries were seen in 4 cases (44%) and major non-vascular injuries in 5 cases (55%). Arterial exposure involved a variety of incisions, including left thoracotomy, median sternotomy, clavicular resection, or a combination of these. Arterial continuity was restored in all cases using primary repair (2), autogenous saphenous vein graft (6), or prosthetic graft (1). Venous injuries were treated by ligation (2) or lateral venorraphy (2). One patient died unexpectedly on the tenth postoperative day for an overall mortality of 11 percent. Three of the 8 survivors sustained nonfatal complications (38%). All 8 survivors had patent arterial repairs at the time of hospital discharge, and 5 of 8 survivors were available for follow-up with intravenous digital subtraction angiography (DSA), revealing arterial repair patency in all.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective, randomized trial of Unna's boots versus hydroactive dressing in the treatment of venous stasis ulcers

In many centers the standard treatment for venous stasis ulcers consists of UB dressings. A new dressing, DuoDERM hydroactive dressing (HD), has recently been used extensively for the treatment of venous stasis ulcers. Because of this trend, a prospective, randomized trial of these two dressings was undertaken. Sixty-nine ulcers (39 HD and 30 UB) were randomized. End points were complete healing and development of complications necessitating cessation of treatment. Time to healing, cost of treatment, and patient convenience were also evaluated. Twenty-one of 30 ulcers (70%) healed with UB therapy compared with 15 of 39 ulcers (38%) treated with HD (p less than 0.01, CST). Life-table healing rates at 15 weeks were 64% for UB compared with 35% for HD (p = 0.01, log rank test). Ten of 39 patients (26%) receiving HD had complications compared with no complications in the UB group (p = 0.004, FET). For those patients whose ulcers healed, there was no significant difference (p = 0.51, STT) in the mean time required for healing or the average weekly cost of dressing materials between the HD group (7.0 weeks at +11.50 per week) and the UB group (8.4 weeks at +12.60 per week). Those patients treated with HD reported a significantly greater level of convenience than those patients with UB (p = 0.004, STT). Although treatment with HD led to better patient acceptance, those patients receiving UB therapy had a significantly greater rate of healing and a significantly lesser incidence of complications than those patients treated with HD.

In situ tibial reconstruction. State-of-the-art or passing fancy

To further evaluate the efficacy of in situ saphenous vein bypass, the authors have reviewed their experience with in situ bypass. Between October 1981 and December 1985, 120 in situ saphenous vein bypass were performed; 81 were to infrapopliteal vessels. All procedures were performed for limb salvage. The mean patient age was 74 years, and 74% were men, 57% had diabetes mellitus, 92% were smokers, and 72% had hypertension and/or coronary artery disease. All patients were evaluated by preoperative noninvasive testing and biplanar angiography. All procedures were performed by the valve incision technique. The vein utilization rate was 91%. Grafts were routinely placed into isolated tibial segments and foot vessels without evidence of a patent pedal arch. Follow-up information was obtained at 3-month intervals. Patency and limb salvage data were calculated by life-table analysis. The cumulative patency rates were 98% at 1 month, 88% at 12 months, and 82% at 50 months. These data demonstrate that the in situ bypass maintains an excellent patency rate and provides durable limb salvage.

Crush syndrome due to limb compression

Four patients with the crush syndrome due to prolonged limb compression were treated at Cook County Hospital, Chicago. Limb injury was caused when the obtunded patient fell asleep lying on the involved extremity. Prolonged limb compression may cause an acute compartment syndrome with ischemic muscle injury. Continued muscle ischemia may lead to myonecrosis resulting in shock or renal failure. A history of prolonged limb compression with a swollen limb should suggest the diagnosis of crush syndrome. Prompt therapy, including rapid correction of volume and metabolic derangements, extensive open fasciotomy, and dialysis for severe acute renal failure should provide good functional results in the majority of patients.