Effect of hypertension and risk factors on diameters of abdominal aorta and common iliac and femoral arteries in middle-aged hypertensive and control subjects: a cross-sectional systematic study with duplex ultrasound.

There is a general tendency towards atherosclerosis and arterial dilatation in older age, and high blood pressure also tends to increase arterial diameters. The purpose of this study was to examine the effect of hypertension and other cardiovascular risk factors on aortic, common iliac and common femoral artery diameters. The diameters of the abdominal aorta and the iliac and femoral arteries and the extent of echogenic plaques in the aorta and the iliac arteries down to groin level were evaluated with ultrasound in 1007 middle-aged (40-60 years) men (505) and women (502), 496 with arterial hypertension and 511 controls. Twenty-eight subjects were excluded because of poor visualization. Men had significantly larger diameters of the abdominal aorta (mean 21.3+/-2.8 vs. 17.8+/-1.3 mm) and the common iliac (13.4+/-2.0 vs. 12.2+/-1.2) and common femoral arteries (11.0+/-1.4 vs. 9.7+/-0.9) than women (P for all <0.001), but arterial diameter was also related to the subject's size. Atherosclerotic plaques, age and height were associated with the diameter of the abdominal aorta in men, while high body mass index (BMI) had less significance. The diameter of the aorta was larger in hypertensive men aged 56-60 than in controls of the same age. In women, height, BMI and diastolic blood pressure (DBP) were associated with the diameter of the aorta, while systolic blood pressure (SBP) had less and age no effect. Age, plaques, height, BMI, DBP and SBP were associated with the diameters of the common iliac arteries in both genders, while smoking had an inverse correlation. The results on lipid values were inconsistent and an abnormal glucose tolerance test proved nonsignificant. In conclusion, arterial size measured as a diameter related to the subject's size was larger in men. Age, arterial plaques and blood pressure increased arterial diameter significantly. However, the hypertensive disease itself had only a minimal effect. The changes were smaller in women than in men.

Antidromic corticospinal tract potential of the brain.

OBJECTIVE: To describe a novel potential component (antidromic corticospinal tract potential, ACSP) of the brain after translaminar spinal stimulation of a relaxed patient during scoliosis surgery. To study the origin of this component and to compare its source to known sources of the somatosensory evoked potentials (SEPs). METHODS: We studied 17 consecutive patients during posterior scoliosis surgery. SEPs and ACSPs were elicited by translaminar spinal stimulation at the Th 2 and L 1 levels. ACSPs and SEPs were recorded on the scalp midline. Neurogenic motor evoked potentials (NMEPs) were recorded on the popliteal spaces. Preoperative tibial SEPs were also recorded. RESULTS: ACSP was distinctly separated from the corresponding spinally evoked cortical SEP that showed longer latency than the ACSP. ACSPs decreased and disappeared when stimulation was moved to the caudal direction in the conus region while SEP persisted. In addition, the hemispheric origin of ACSP was confirmed with multichannel midline recordings of the scalp and neck. Thus there was no confusion to the response of nucleus gracilis, corresponding the P 31 response of the tibial nerve SEP. CONCLUSIONS: The origin of ACSP seemed to be in the rostral part of the corticospinal tract. ACSP diminished in the conus region when stimulation was moved caudally and it disappeared when the stimulus was given to the root level. This proves that ACSP is not a response of the somatosensory tract, instead ACSP represents antidromic response of the pyramidal tract. ACSP can be used in monitoring of the motor tracts during scoliosis surgery together with NMEPs.

Effect of hypertension, diabetes and other cardiovascular risk factors on kidney size in middle-aged adults.

The aim of the study was to investigate in a population-based series (1031 subjects, age range 40-60 years) whether the renal size of hypertensive subjects differs from that of control subjects and whether the difference might be due to hypertension itself or risk factors associated with hypertension. The renal measurements were performed by abdominal ultrasound. The genders were analyzed separately. Hypertensive men had slightly larger kidneys than controls (70.1+/-8.9 cm2 vs. 67.9+/-8.7 cm2, p <0.008). The difference was, however, mediated mainly through the body mass index (BMI), whereas hypertension, blood pressure or hypertensive medication did not affect renal size. High serum concentrations of uric acid and creatinine were associated with smaller kidney size (p <0.001 and p <0.05, respectively). Alcohol users had slightly larger kidneys than abstainers, but the difference was not significant. Renal size increased with pack years of smoking. Diabetics had 4.8% larger kidneys (p <0.039), but no difference was observed between the subjects with impaired glucose tolerance and those with normal test results. In multivariate analysis, the most significant factors associated with enlarged kidney size were the fasting blood glucose concentration (p < or = 0.0001), smoking (p < or = 0.0001) and atherosclerotic lesions in carotid arteries (p <0.002). The kidneys were also slightly larger in hypertensive women than in control subjects, but the difference was only of borderline significance (p <0.08). Women on hormone replacement therapy had smaller kidneys than other women (p <0.05), but there was no difference in renal measures between premenopausal and postmenopausal women. In multivariate analysis, the most significant factors contributing to large kidney size were blood glucose concentration (p <0.0001) and smoking (p <0.05), while age and serum creatinine concentration were associated with smaller kidney size (p <0.0001 and p <0.0001). We conclude that renal size is related to sex and the subject's height and weight. Smoking, abnormal glucose tolerance, blood uric acid, creatinine, carotid atherosclerosis and hormone replacement therapy in women were also significant factors for renal size. Hypertensive subjects had larger kidneys than controls, mainly because of their more frequent obesity and abnormal glucose test.

Ultrasound in the detection of adrenal tumours.

An analysis was made of the ultrasound (US) findings in 110 patients with proven or ultrasonographically suspected adrenal tumours. A total of 212 glands were imaged, 117 of which contained a tumour. The diagnosis was confirmed histologically in 50 cases and by imaging and follow-up in 162 cases. Normal glands were visualized ultrasonically in 27 out of 40 glands on the right and 5 out of 55 on the left. US detected 55 out of 59 primary adrenal tumours and 49 out of 58 secondary tumours, showing a sensitivity of 89%. In 13 tumours ultrasonography gave a false negative result, and in 13 cases a false positive one. Benign or primary malignant tumours and metastases could not be differentiated on the basis of echo-structure, but a large heterogeneous tumour in a patient with no known extra-adrenal malignancy is probably a primary malignant adrenal tumour.

Assessing resectability of lung cancer: the role of computed tomography of the mediastinum, upper abdomen and head.

In order to assess the value of computed tomography (CT) of the mediastinum, upper abdomen and head in the assessment of resectability of lung cancer, the CT findings of 262 patients, of whom 198 underwent thoracotomy, were analyzed retrospectively and the stagings obtained at CT and thoracotomy were compared. Mediastinal CT reliably predicted resectability when there was no evidence of mediastinal involvement. However, it was often impossible to determine whether tumour with apparent mediastinal infiltration on CT was resectable or not. The sole finding of lymph node enlargement did not permit differentiation of benign from malignant lymphadenopathy when the lymph node diameter was less than 25 mm and the lymphadenopathy was confined to one lymph node station. Upper abdominal metastases were found in 6.1% and brain metastases in 4.6% of patients and neither the histological type nor other features of the tumour were found to be useful predictors of their presence. The large number of non-specific findings decreased the utility of abdominal CT. The appropriate strategy for the pre-operative evaluation of patients with lung cancer is discussed.

The spine in diastrophic dysplasia.

Diastrophic dysplasia is an autosomal recessive disorder of the skeleton, characterized by disproportionate short stature, generalized joint deformities, club feet, deformed ear pinnae, and, frequently, spinal deformity and cleft palate. Diastrophic dysplasia is more common in Finland than elsewhere. We studied 101 patients with an age range from newborns to 79 years to find out the frequency and type of spinal deformities, the early signs of progressive cases, and to follow the natural history of the disease. In the follow-up study, 17 patients were under 10 years, 21 under 21 years, and 63 over 21 years of age. One-third of the patients had cervical kyphosis; in the most severe case the kyphosis was 180 degrees and led to quadriplegia during anesthesia. In three patients, cervical kyphosis resolved spontaneously before the age of 5 years. The overall frequency of scoliosis was 37%; 49% in women and 22% in men. Only 13 patients had curves greater than 50 degrees; these curves constituted distinct rotation at the apex from the early evolution of the curve. The early signs of severe curves were detectable at the age of 2 to 4 years. Only two patients were operated on because of scoliosis; one with fusion in situ and the other instrumented with the pediatric Cotrel-Dubousset instrumentation. Three patients had a brace, which did not prevent the progression of the curve. Symptoms referring to a narrow spinal canal were registered in four patients, two of which were operated on; a lumbar posterior decompressive procedure was made at adult age.

Radiological and cytological detection of renal pelvic transitional-cell carcinoma.

We evaluated US, CT, intravenous urography, arteriography, retrograde pyelography and urine cytology results in a series of 23 patients with renal pelvic transitional-cell carcinomas, 14 of whom underwent US, 17 i.v. urography, 8 CT, 15 arteriography, 9 retrograde pyelography, and 17 patients urine cytology. A tumour was identified in 5 patients (36%) at US, in 11 patients (61%) at urography, in 7 (88%) at CT, in 10 patients (67%) at arteriography, and in 8 (89%) at retrograde pyelography. Urine cytology was assessed as showing changes consistent with Papanicolaou class III-V in 15 (88%) of 17 patients. When renal pelvic cancer is suspected, intravenous urography should be performed as the initial radiological examination and followed by CT, which may also identify tumour spread. Arteriography and retrograde pyelography are sometimes complementary investigations. Repeated urinary cytology is mandatory. Our results show that US alone is unreliable in detecting renal pelvic cancer.

Foot deformities in diastrophic dysplasia. An analysis of 102 patients.

The exceptionally high prevalence of diastrophic dysplasia in Finland has enabled us to analyse the foot deformities of 102 patients at their first orthopaedic evaluation and classify 204 feet into five categories. The most common finding (43%) was a foot with tarsal valgus deformity and metatarsus adductus; 37% showed either equinovarus adductus (29%) or equinus (8%) deformities. At the first examination 13% showed metatarsus adductus deformity alone, and 7% were clinically normal. The expression 'club foot', generally used for the foot deformity in diastrophic dysplasia is a misnomer. There is a wide spectrum of deformities, some of them specific for the condition.

Development of the hip in diastrophic dysplasia.

We examined 50 patients with diastrophic dysplasia both clinically and radiologically. Two legally aborted fetuses were dissected. The mean age of the patients was 16.2 years (newborn to 38) and the mean follow-up was 11.4 years (3 months to 34 years). The fetal hips and MRI of newborn infants showed congruity and no significant joint deformity. Flexion contracture of the hip became evident later in 93% and was progressive. The radiological appearance of the proximal femoral ossific nuclei was delayed and in 17% of males and 28% of females the ossific nuclei had not appeared by the age of 12 years. Radiological measurements differed considerably from reference values and were related to the rapid and progressive restriction of rotational movement and the increase in flexion contracture. The typical findings were flattening and inferomedial bulking of the femoral head and a double-hump deformation. The changes in the hip led to secondary osteoarthritis before early middle age. We describe the clinical and radiological measurements which define the early degeneration of the joint.

Intra-familial child homicide in Finland 1970-1994: incidence, causes of death and demographic characteristics.

The purpose of this study was to investigate all child homicides for the 25-year period, 1970-1994 in Finland and to analyse the specific characteristics of the filicide cases. A total of 292 child homicides occurred during this period. In 201 (69%) cases the offender was a parent or a stepparent of the child. Altogether, 173 (59%) of the victims were boys and 119 (41%) were girls. For the closer examination of the filicide cases we excluded the neonaticide and homicide-suicide cases. Consequently, we report on 70 filicide victims. Of these victims, 42 (60%) were boys and 28 (40%) were girls. Twenty six (37%) of the children were killed before the age of 1 year and 53 (79%) before the age of 5 years. The offender was the mother in 43 (61%) cases and the father or the stepfather in 26 (37%) cases. The victims of the mothers were younger than those of the fathers. The most frequent causes of death were head injuries, drowning and suffocation. The most common means of assault were battering, drowning and strangulation. One in two of the fatally battered children had a documented history of previous abuse.

Immunologic consequences of neonatal splenectomy.

The hazard of overwhelming postsplenectomy infection has been suggested to be greatest in children operated upon before 1 yr of age. In this work immune functions of 3 children, splenectomized within 2 days after birth were studied. The opsonic activity of the sera of all patients towards pneumococcus was decreased. The other immunologic findings were normal. These observations support the concept that all splenectomized patients should receive pneumococcal polysaccharide vaccine and in case of any infection adequate antibiotic therapy must be started very soon after the first symptoms.

Percutaneous cholecystostomy in acute cholecystitis in high-risk patients: an analysis of 69 patients.

BACKGROUND: Optimal treatment of acute cholecystitis in high-risk patients with acute cholecystitis continues to be a difficult therapeutic problem. With the development of more advanced radiological imaging techniques, percutaneous cholecystostomy (PCS) has been presented as an effective treatment alternative in critically ill patients. This paper reports our experiences of percutaneous cholecystostomy in the treatment of acute cholecystitis in a well defined high-risk patient group. METHODS: The data concerning 69 high-risk patients with acute cholecystitis treated by percutaneous cholecystostomy in Oulu University Hospital and Kokkola Central Hospital were analyzed. RESULTS: Ultrasound showed gallbladder stones in 71% (49/69) of the patients and 29% of them presented with acalculous cholecystitis. After PCS, pain diminished in 94% (61/65), fever in 90% (35/39), CRP values in 87% (53/61) and leucocyte count in 84% (46/55) of the patients. Before PCS, the CRP value was 132+/-106 mg/l and after PCS 79+/-73 mg/l (P = 0.001) and corresponding leucocyte counts were 14.7+/-5.0 and 9.3+/-3.2 (P = 0.001), respectively. The antegrade cholecystocholangiography was performed in 29 patients after PCS, and common bile duct stones were detected in 8 patients; these stones were treated by endoscopic papillotomy. Complications after PCS occurred in 17 patients (26%), but only two patients required emergency laparotomy. Mortality was 19% (13/69). Acute cholecystitis alone was the cause of death in only three patients. Mostly, fatal outcome was caused by the serious underlying diseases. CONCLUSION: According to our results, PCS should be the method of choice in high-risk patients with acute cholecystitis.

Critical aspects of neonatal surgery in clubfoot.

Good results after early operative treatment of clubfoot has been reported by some investigators. Most have recommended early conservative treatment and later surgical procedures in resistant cases. Operation immediately after birth is demanding, and the operative team must master all problems of neonatal surgery, anesthesiology, and postoperative care. Conservative treatment in experienced hands may lead to a satisfactory result in one third of cases. We recommend primarily conservative treatment, but patients with resistant cases must undergo operation at age 2-5 months. We need more prospective studies and generally accepted grading systems of results.

Outcome of Perthes' disease in unselected patients after femoral varus osteotomy and splintage.

We evaluated 56 hips (48 patients) with Perthes' disease to compare the radiographic results of two unselected groups: one treated with femoral varus osteotomy (22 hips) and another with Thomas splint (34 hips). The patients with less than 50% femoral head involvement (Salter Group A hips) seemed to have no advantage from the operation. The angle of the femoral neck was 10 degrees less in the operative group than in the nonoperative group. In hips with more than 50% head involvement (Salter Group B), the operative method resulted in slightly better coverage and sphericity of the femoral head than the conservative method. On average, the acetabular direction was similar in both groups. The authors conclude that femoral varus osteotomy may lead to residual coxa vara and does not necessarily improve the radiographic results in limited epiphyseal involvement. Neither does the operation have an effect on the acetabular direction in severe Perthes' disease.

Free fat transplant prevents osseous reunion of skull defects. A new approach in the treatment of craniosynostosis.

Free fat tissue transplant to correct premature epiphyseal fusion of long bones has been successfully used to prevent re-ossification after bone bridge resection. In the present study we have applied this principle in the prevention of osseous reunion of the bone defect in the calvaria of the rabbit. In two-week-old animals standard bone defects were made on both sides of the sagittal suture to the temporal bone. The dura was left intact. On the right side a free autogenous fat transplant was placed to fill the bone defect. On the left side the control defect was left without fat interposition. The skull defects were examined postoperatively at three weeks, three months, and eight months. The control defects reossified within three weeks. The bone defects with fat tissue transplant were found to be open and of original size at eight months postoperatively. On the transplanted side histological examination revealed living fat cells filling the gap. Osteogenesis was inhibited and reunion of the bone edges was prevented. All the control bone defects were filled by lamellar bone. The use of free fat tissue transplant can be a useful alternative, serving as a biological interposition material in the surgical treatment of craniosynostosis.

Use of self-reinforced polylactide osteosynthesis devices in craniofacial surgery: a long-term follow-up study.

Self-reinforced polylactic acid or polylactide (SR-PLA) is a biodegradable polymer, which is strong enough to fix weight-bearing cortical bone fractures and osteotomies. We report our experience and follow-up of the use of SR-PLA plates in 15 clinical cranioplasties. Two of the cases are described in greater detail. In one of them SR-PLA plates were used in addition to titanium plates, and in the other an SR-PLA plate fixed with mini-titanium screws was used as the only fixation material. In the other patients SR-PLA plates or wire were used in addition to titanium. So far no complications have been observed in these 15 patients. The only small superficial fistula was associated with a titanium plate and titanium screws. The longest follow-up has been over eight years. Recent results show metal-like deformation properties in addition to complete late resorption, making SR-PLA osteosynthesis devices promising for use in craniofacial surgery.

A new mini-invasive technique in treating pediatric diaphyseal forearm fractures by bioabsorbable elastic stable intramedullary nailing: a preliminary technical report.

BACKGROUND AND AIM: Operative treatment is often indicated in unstable pediatric diaphyseal forearm fractures. Recently minimally invasive reduction and elastic stable intramedullary nailing have been of increasing interest, instead of open reduction and internal fixation with plates. There are several disadvantages of metallic intramedullary implants, such as soft-tissue irritation and a risk of disturbing later imaging. Thus, they are generally removed in later operations. We aimed to develop a new technique to stabilize pediatric forearm fractures by the bioabsorbable intramedullary nailing. MATERIAL AND METHODS: We developed a new, two-stage mini-invasive surgical technique to stabilize the unstable diaphyseal fractures in children. The procedure is bioabsorbable elastic stable intramedullary nailing. Ultra-high-strength bioabsorbable intramedullary nails of poly(lactide-co-glycolide) were manufactured for our purpose. The material has been widely proven to be biocompatible and stable enough for fracture treatment as screws and pins. We have used the new technique in the unstable both-bone diaphyseal forearm fractures in children between the ages of 5 and 15 years. We report the technique and our clinical experience in the series of those three cases that have been followed up for at least 12 months. The present series has been randomized for the procedure instead for titanium elastic stable intramedullary nailing, and the series represents a part of ongoing randomized trial. RESULTS: The reported cases operated by the new technique referred good union in the fractured bones and acceptable alignment in the follow-up. Removal of the implants was not required. No troubles with the procedure or implant per se were noticed, indicating good feasibility. One high-energy refracture occurred half year after the primary trauma. Traditional titanium implants were used to control the refracture. CONCLUSIONS: We report our preliminary experience of a new surgical mini-invasive procedure to stabilize the unstable pediatric forearm shaft fractures by bioabsorbable elastic stable intramedullary nailing. Our clinical experience suggests that the procedure combined with long-arm casting is feasible in treating the pediatric forearm fractures. The technique may bring benefits to handling these challenging fractures. The disadvantages of metallic implants may be avoided. In addition, removal of the implant will not be required. There was one refracture in the series, but it was due to new high-energy trauma. According to our understanding, it was not related to the type of former osteosynthesis. However, ignoring the good preliminary experience, still we do not have results of the superiority of the procedure over traditional elastic stable intramedullary nailing. Our ongoing randomized multicenter study is aimed to determine its long-term outcome against the present golden standard. Nevertheless, due to encouraging preliminary results, we see it necessary to report the technique.