The prevalence and characteristics of pruritus in patients with heart failure.

BACKGROUND: Pruritus (itching) can be a distressing symptom, and previous research suggests that it is common in patients with chronic heart failure (CHF). OBJECTIVES: The primary aim was to examine the prevalence of itching in patients with CHF and to compare this first to that among patients with coronary artery disease (CAD) and second to that of a normal Swedish population. The study also explored characteristics and possible causes of pruritus in patients with CHF. METHODS: In this cross-sectional prevalence study, a questionnaire was sent to 130 patients with CHF and to 130 with CAD. A total of 85 patients with CHF (65·4%) and 82 with CAD (63·1%) participated. Data were also compared with those of a previous study examining symptoms in a normal Swedish population. RESULTS: The prevalence of itching at some point during the last 3 months was 40·0% in patients with CHF and 23·2% in patients with CAD (P = 0·019). This difference was not significant after adjusting for sex, age and medication. Patients with CHF described their pruritus as more disturbing than patients with CAD. In addition, 13·6% of patients with CHF and 3·8% of persons in the normal population experienced itching every week without any rash (P = 0·001). CONCLUSIONS: Pruritus is common and sometimes disturbing in patients with CHF and warrants clinical attention. Medication should be considered as a cause of itching and may explain differences in the prevalence between patients with CHF and those with CAD. However, other causes of itching in patients with CHF should be explored in prospective studies.

Post-operative 3-dimensional contrast-enhanced ultrasound (CEUS) versus Tc99m-DTPA in the detection of post-surgical perfusion defects in kidney transplants - preliminary findings.

PURPOSE: 2800 renal transplants are carried out annually in the UK and it is standard practice to perform a Tc-DTPA renogram examination after surgery to check perfusion. This provides some functional information but suffers from low spatial resolution, is lengthy, immobile and costly and uses ionizing radiation. We surmised that contrast-enhanced ultrasound (CEUS) would provide an accurate alternative with increased speed, resolution (temporal and spatial), cost efficiency and safety. MATERIALS AND METHODS: 97 renal transplant patients underwent both Tc-DTPA and CEUS after surgery to assess the perfusion of the graft. Tc-DTPA was performed in the nuclear medicine department with at least 10 minutes of continuous screening and a standard dose of 150 mBq Tc-DTPA. CEUS consisted of I. V. 2.4 ml Sonovue contrast agent, 60 seconds continuous capture and a 3 D acquisition of the organ. 3 D CEUS was assessed using QLab analysis software. RESULTS: Tc-DTPA detected 9 perfusion defects of varying size. CEUS detected all these defects plus 14 further defects (0.2 - 17 % of total renal volume) not detected on DTPA. These results demonstrate a statistically significant divergence (p < 0.0001). Retrospective clinical correlation showed ligated polar arteries in 8 of these 14 cases. CONCLUSION: CEUS will detect perfusion defects seen with Tc-DTPA and due to increased spatial and temporal resolution and multiple scanning angles, will detect further perfusion defects not seen on Tc-DTPA. 3 D CEUS is useful in the quantification of perfusion defects. CEUS is an accurate examination for detecting renal transplant perfusion defects and will detect significantly more defects than DTPA.

Scoring of hand eczema: good agreement between patients and dermatological staff.

BACKGROUND: Assessment of hand eczema in a clinical study has been achieved using a scoring system which documents extent of eczema on different areas of the hand. OBJECTIVES: To investigate whether the same scoring system could be used by patients to communicate current status of hand eczema. METHODS: In a study of 62 patients (36 women and 26 men, age range 19-75 years), the patient's own assessment was compared with the assessment by a dermatologist and a dermatological nurse. Standardized information was given to the patient and the form was filled in independently by the patient, the nurse and the dermatologist, during the patient's visit to the clinic. Individual area scores were summed to a total score. RESULTS: The overall agreement was good, with an interclass correlation (ICC) of 0·61 between patient and dermatologist for the total score. The ICC between nurse and dermatologist was 0·78. Differences between observers were more pronounced for the more severe cases - those with higher numerical scores as assessed by the dermatologist. There was a tendency for women and for patients over the median age of 44 years to set a lower point score than the dermatologist. The concordance of observations from individual anatomical areas was higher for fingertips and nails and lower for the palm and dorsum of the hand. CONCLUSIONS: Patients are able to report the extent of hand eczema with good accuracy. Self-assessment protocols for hand eczema may well have a place in the monitoring of hand eczema extent over time.

A new technique for assessing renal transplant perfusion preoperatively using contrast-enhanced ultrasound (CEUS) and three-dimensional ultrasound (3DUS)--a porcine model pilot study.

PURPOSE: This pilot study aims to assess the viability of using contrast-enhanced ultrasound (CEUS) in renal grafts while they are on hypothermic perfusion machines prior to transplantation. We assessed the vascularity and renal perfusion of machine-perfused porcine kidneys (Maastricht category II) using CEUS. MATERIALS AND METHODS: Five kidneys were placed on hypothermic machine perfusion for up to 24 hours after retrieval. The kidneys were then scanned with a low MI contrast-specific preset and a bolus of 0.5 ml of Sonovue contrast agent was administered. Contrast-specific ultrasound images of the kidney were acquired in 2D and 3D. RESULTS: The five kidneys demonstrated variable flow rates on the perfusion machine (10 - 37 ml/min at 30 mmHg). The CEUS technique demonstrated good perfusion and flow patterns, similar to those seen in vivo, in four kidneys. One kidney had patent arteries up to the interlobar region but no contrast filling in the cortex or medulla. Small perfusion defects were seen in two of the perfused kidneys. CONCLUSION: CEUS appears to be a viable technique for assessing global perfusion and small defects within kidneys prior to transplantation. The flow patterns seen in vitro appear to correspond to those seen in vivo. Further work is required to evaluate the relevance of the flow dynamics measured.

Changes in health over time in patients with symptoms allegedly caused by their dental restorative materials.

OBJECTIVES: In Sweden, many patients with symptoms allegedly caused by their dental materials have exchanged their restorations, but the effects of the exchange have been insufficiently investigated. Therefore, the aim of the study was to describe the change in health over time for these patients and the hypothesis was that the patients could be divided based on their symptoms and that the ability to recover differs between these groups. Furthermore, we also examined if other factors such as replacement of dental restorative materials and follow-up time had any impact on the perceived health status. METHODS: A questionnaire was sent to 614 patients who had been referred to the School of Dentistry, Umeå, Sweden, with symptoms allegedly caused by dental restorative materials. The response rate was 55%. RESULTS: The risk of having any further complaints was higher for patients with complex symptoms (P = 0.03) and these patients had exchanged their restorations to a significantly larger extent than the others (P = 0.03). The remaining complaints was more frequent among men (P = 0.02). Exchange of dental restorative materials had no significant impact on the ability to recover completely. However, the patients who had exchanged their restorations completely perceived a significantly larger alleviation of their symptoms than the others (P < 0.01), although the frequency of most of the symptoms had increased. CONCLUSIONS: Patients with complex symptoms had a more unfavorable long-term prognosis concerning persistent complaints than those with localized symptoms only. Furthermore, the results indicate that the patients might experience health improvements after removal of their dental restorative materials. The reason for this improvement, however, is unclear. Further analyses regarding other possible explanations than the 'odontological/medical' are needed.

Effect of venous stasis on vessel wall fibrinolysis.

The effects of prolonged venous stasis on release of plasminogen activators (PA) from the caval vein of rats were studied. PA activity was continuously reduced in the intimal layer and after 8 hr of stasis the reduction was statistically significant. After 2 and 3 days no intimal PA activity was found. The PA activity in the adventitial vasa vasorum was unchanged during the experimental period.

Tranexamic acid and gastric fibrinolysis in the rat.

An optimal inhibition of tissue fibrinolysis, studied by a histochemical fibrin slide technique in the rat stomach, was obtained by administration of tranexamic acid in a dose of 60 mg/100 g body weight. A significant fibrinolysis inhibition was found within 5 min, when tranexamic acid in this dose was given either intravenously or intragastrically. A prolonged duration of fibrinolysis inhibition was observed after intragastric administration. After 4 hr no inhibitory effect of tranexamic acid could be recorded, irrespective of the route of administration.

Reduction of gastric haemorrhage by fibrinolysis inhibition - an experimental study in rats.

Gastric ulcerations were induced in rats by pyloric ligature and instillation of 1.0 N HCl. After four hours all rats had developed ulcerations. Increased release of plasminogen activators from the mucosa during these conditions has previously been demonstrated. In the present study we investigated the role of fibrinolysis inhibition versus H2-receptor blockade on the gastric bleeding. Tranexamic acid - a synthetic inhibitor of the fibrinolytic system - was found to significantly (p less than 0.01) reduce blood loss into the gastric juice by 30% measured by 51Cr labelled red blood cells; cimetidine did not reduce the gastric haemorrhage under the experimental conditions used. Both treatment regimes significantly (p less than 0.02) reduced the secretion of gastric juice. These results indicate a contribution of the fibrinolytic system in gastric bleeding from experimentally induced gastric ulcerations.

Localization of tissue fibrinolysis in the gastrointestinal tract.

Tissue fibrinolysis in the stomach and intestine of the rat was studied with a histochemical technique. After perfusion of blood vessels to reduce the influence of circulating plasminogen activator and inhibitor fibrinlysis was localized mainly to submucosal arteries and to the serosa of the gastrointestinal tract. This is opposite to previous observations, in which tissue fibrinolysis in the gastrointestinal tract was suggested to be mainly localized to veins. A method for semiquantitative analysis of tissue fibrolysis in the rat stomach is described.

The Sick Building Syndrome (SBS) in office workers. A case-referent study of personal, psychosocial and building-related risk indicators.

BACKGROUND: The Office Illness Project in Northern Sweden, comprising both a screening questionnaire study of 4943 office workers and a case-referent study of Sick Building Syndrome (SBS) in 464 subjects was recently completed. Previously published results from the survey showed that female gender asthma/rhinitis, high psychosocial work load, paper and visual display terminal (VDT) work were related to an increased prevalence of SBS symptoms. METHODS: The case-referent study presented in this paper used data from the questionnaire supplemented with information from a clinical examination, a survey of psychosocial factors at work building data from inspection and measurements taken at the work sites. RESULTS: Personal factors such as atopy and photosensitive skin, psychosocial conditions and physical exposure factors influencing indoor air quality (IAQ), such as outdoor air flow rates and the presence of photocopiers were related to an increased prevalence of the reported SBS symptoms. The results were established using multivariate analysis. CONCLUSIONS: The rate response relationship between actually measured ventilation rates and the prevalence of perceived SBS symptoms presents strong evidence for the association between IAQ factors and health.

The psychosocial work environment and skin symptoms among visual display terminal workers: a case referent study.

BACKGROUND: This study is a part of the interdisciplinary project The Office Illness Project in Northern Sweden, which was initiated with a questionnaire study in late 1988. Previously published results from the project have shown that facial skin symptoms reported among visual display terminal (VDT) workers are associated with a number of exogenous factors. This part of the project investigated the relation between the psychosocial work environment and facial skin complaints. METHODS: From an initial questionnaire study among 4943 office workers, 163 VDT workers were selected for a case referent study of facial skin symptoms. The data comprise a self-administered questionnaire filled out by 149 subjects and interviews with representatives of the organizations concerned. RESULTS: Psychosocial conditions, especially lack of social support from co-workers, were associated with an increased risk of reporting skin symptoms. Stratification by sex showed that the associations between some psychosocial factors and health differed between men and women. The results indicate that there might be an interaction between psychosocial factors and electric fields in the workplace which increases the risk of reporting skin symptoms. CONCLUSIONS: This study supports the idea that the aetiological basis of facial skin symptoms among VDT-workers includes physical as well as psychosocial factors, and that the interaction between such factors might be significant in the understanding of skin complaints among VDT workers.

Facial skin symptoms in visual display terminal (VDT) workers. A case-referent study of personal, psychosocial, building- and VDT-related risk indicators.

BACKGROUND: The Office Illness Project in northern Sweden, comprising both a screening questionnaire study of 4943 office workers and a case-referent study of facial skin symptoms in 163 subjects was recently completed. Previously published results from the survey showed that female gender, asthma/rhinitis, high psychosocial work load, visual display terminal (VDT) and paperwork were related to an increased prevalence of facial skin symptoms. METHODS: The case-referent study presented in this paper used data from the questionnaire supplemented by information from a clinical examination, a survey of psychosocial factors at work, building data and VDT-related factors from inspection and measurements taken at the work site. RESULTS: Psychosocial conditions and exposure to electromagnetic fields or conditions associated with such factors were related to an increased occurrence of skin symptoms. The results also indicated that personal factors such as atopic dermatitis and physical exposure factors influencing indoor air quality, such as paper exposure and cleaning frequency were related to an increased prevalence of symptoms. CONCLUSIONS: The results suggest that skin symptoms reported by VDT users have a multifactorial background.

Modulation of tissue fibrinolysis from hypoxia and hyperoxia.

The effects from alterations in inspired oxygen tension on the fibrinolytic activity in vessel walls was studied in rats. Tissue plasminogen activator activity was measured semiquantitatively with the histochemical technique. During severe hypoxic conditions (FIO2 = 0.05) the fibrinolytic activity in the aorta was significantly reduced as compared to control animals. At 24 hours with slightly higher oxygen tension (FIO2 = 0.08) the activity was increased. When breathing pure oxygen (FIO2 = 1.0) the fibrinolytic activity was increased in the aorta after 8 hours. Following chronic hypoxia for 6 weeks (FIO2 = 0.1) the activity in the caval vein was increased. Changes in inspired oxygen tension thus affected the endothelial cells and changed their expression of plasminogen activator activity.

Why do women report 'sick building symptoms' more often than men?

The prevalence of general, mucosal and skin symptoms compatible with the 'Sick Building Syndrome' (SBS) was studied in Swedish office workers. The marked excess in symptom prevalence among females, 12% SBS cases as compared to 4% among males, was analysed with respect to differences in biological or acquired risks and different illness and reporting (interview) behaviour among males and females. The distribution of risk indicators for symptoms was recorded in a questionnaire to 4943 employees. The skin symptom questions were validated in a clinical examination. Most risk indicators, such as paper work and psychosocial work load, had an unfavourable distribution for females. In the multivariate analysis however, female sex remained the most prominent risk indicator almost unaffected by the addition of other factors. Neither did effect modification contribute to the excess prevalence among females. The results from the clinical examination indicate that the excess symptom prevalence among females is real and not a reporting artefact. As the factors studied did not explain the excess symptom prevalence among females, the sex differential observed can be a reflection of a general excess of psychosomatic symptoms among women. Although inequalities in social conditions did not substantially explain the sex differential in symptom reporting, the importance of life situation and social roles should be further explored. As the studied variables are surrogates for actual measurements, another important issue is whether sex differences in working conditions, entailing different hierarchical positions in the office, have consequences for indoor air quality factors that are important for the symptoms. The study strongly underlines the importance of taking the sex distribution into account when surveying risk indicators for SBS symptoms.

Facial skin symptoms in office workers. A five-year follow-up study.

This longitudinal study is a part of the interdisciplinary project. The Office Illness Project in Northern Sweden, which was initiated with a questionnaire study in late 1988. Among 3233 visual display terminal (VDT) workers, an initial case-referent group of 163 individuals was selected. The data acquisition included two questionnaires, assessments at the workplaces, interviews with personnel staff of the organizations concerned, and a clinical examination of the respondents. Subjects participating in the case-referent study 1988 filled out a questionnaire in the beginning of 1994. The primary objective of this study is to discuss changes in and causes of facial skin symptoms among VDT workers in the long term. The results show that (1) facial skin symptoms among VDT workers seem to be of a transitory nature for most of those with isolated skin symptoms, whereas the prognosis for those with a more complex symptom picture is more negative, (2) assumptions that measures taken in the work environment-including those involving the VDT and other electric devices-would have a positive effect on symptoms were not supported, and (3) the strongest external risk indicators for lasting skin symptoms seem to be found in the psychosocial work environment. Therefore, one important issue for the understanding of facial skin symptoms is organizational climate and personnel policies. The results also imply that individual factors, both constitutional and psychological, must be considered.

Wound healing alterations caused by infection.

The theoretical alterations of wound healing caused by infection apply to the clinical situation. The level of bacteria is clinically important as are the specific qualities of a given species. This latter consideration has not been as completely studied as have the quantitative aspects. However, as pharmacologic means of overcoming the wound healing alterations are sought, specific bacterial species' idiosyncrasies will have to be examined. This has already been identified for the beta-hemolytic streptococcus. That species has not adhered to the level of greater than 10(5) organisms to produce wound complications. It has been repeatedly shown to cause wound problems at a much lower inoculum. Similar information may become available for other organisms. However, it is clear that because wound healing in the clinical situation occurs in the presence of bacteria, it is important to be aware of potential alterations in the repair process that these bacteria can cause.

The first Swedish case of congenital erythropoietic porphyria, with a revised view of the porphyrin excretion pattern in this disease.

A case of congenital erythropoietic porphyria (CEP) in a Swedish boy is described. It is the second case of this extremely rare disease encountered in Scandinavia. Like the first Scandinavian case--a Norwegian boy--this patient showed a porphyrin excretion pattern like that of porphyria cutanea tarda (PCT) which was regarded as pointing to a hepatic type of porphyria. In the Norwegian boy this was regarded as atypical, but our study of the literature revealed two older cases with features pointing to a similar pattern and disclosed that analysis of the porphyrin pattern with modern methods, such as thin-layer chromatography, has not been performed in the great majority of the cases of CEP, because such methods were not available at the time these cases were published. Therefore, it is necessary to study more cases of CEP with modern analytical methods in order to get an adequate picture of the porphyrin pattern typical of this disease.

Long-term assessment of the effects of circumferential truncal burns in pediatric patients on subsequent pregnancies.

Longitudinal assessment of the long-term effects of pediatric circumferential truncal burns on subsequent pregnancies is poorly documented. Between December 1967 and August 1985, 75 female pediatric patients with circumferential truncal injuries were admitted to our institution. Twenty-two of these patients were available for long-term follow-up into early adulthood. Seven of these 22 patients had conceived. All seven patients had sustained flame-burn injuries. Mean age at injury was 7.66 +/- 2.12 years. Mean total body surface area of burns was 63.21% +/- 16.69%, with 44.21% +/- 17.54% of the injuries full thickness. Each patient was treated with excision and split-thickness skin grafting during initial hospitalization. In the group of seven patients there were 14 pregnancies. All infants were full term. There were 13 vaginal deliveries and one elective cesarean section. Prenatal complications were limited to one case in which a patient had sustained breakdown of scar tissue during the third trimester of pregnancy. There were no labor and delivery complications in this patient population. Circumferential truncal burns appear to have no impact on prenatal or labor and delivery complications.

Bactericidal and wound-healing properties of sodium hypochlorite solutions: the 1991 Lindberg Award.

Toxic effects of sodium hypochlorite on wound healing elements have been confined to a restricted range of sodium hypochlorite concentrations. We investigated concentrations of sodium hypochlorite for antibacterial activity and tissue toxicity at varying time intervals. We attempted to find the efficacious therapeutic concentration that was both microbicidal and nontoxic. Gram-negative and gram-positive isolates (0.1/ml of 1 x 10(8)/ml) were introduced into various concentrations of buffered and unbuffered sodium hypochlorite solutions for determinations of bactericidal activity at 5-, 10-, 15-, and 30-minute intervals. Concentrations of sodium hypochlorite were 0.25%, 0.025%, and 0.0125%. In vitro assays with fibroblasts at the same concentrations were also performed to determine toxicity at the same time intervals. An in vivo incisional model was also used to determine the effects of sodium hypochlorite therapy on wound healing. Bactericidal effects were observed for concentrations as low as 0.025%. Tissue toxicity, both in vitro and in vivo, was observed at concentrations of 0.25% but not at a concentration of 0.025%. Although concentrations below this level were nontoxic, they were not bactericidal. Therefore a modified "Dakin's" solution at a concentration of 0.025% is therapeutically efficacious as a fluid dressing, since it preserves bactericidal properties and eliminates the detrimental potential on wound healing.

Coping and self-image in patients with symptoms attributed to indoor environment.

This study investigated self-image and coping ability in a group of patients with symptoms from indoor environment. A follow-up questionnaire was sent to 239 patients previously referred with nonspecific building-related symptoms at University Hospital in Umeå, Sweden. One hundred seventy-four women and 14 men answered and the patient group rated their self-image as more spontaneous, more positive, and less negative than a control group. The patient group rated higher on the cognitive scale in the Coping Resources Inventory (CRI) than the control group. The female patients had an increased risk of not being able to work associated with a low score on negative self-image. The authors conclude that certain personality traits may be potential risk factors that increase the probability of encountering and experiencing stressful work situations. The resulting stress may increase workers' susceptibility to indoor environment exposure.