Evaluation and comparison of cathodic trypsin-like immunoreactivity, pancreatic lipase and pancreatic isoamylase in the diagnosis of acute pancreatitis in 849 consecutive patients with acute abdominal pain.

In 849 patients (417 men, 432 women) consecutively hospitalized with acute abdominal pain we compared the value of serum cathodic trypsin-like immunoreactivity, pancreatic lipase (EC 3.2.1.3) and pancreatic isoamylase (EC 3.2.1.1) as diagnostic tests for acute pancreatitis. The diagnoses of acute pancreatitis (in 49 patients, 5.8%) and other diseases were made without knowledge of these enzyme values. When evaluated by means of receiver operating characteristic curves no differences were found in diagnostic performance of the three enzymes. Use of combinations of different enzymes had no advantage over single enzyme determination using discrimination analysis for evaluation. The highest efficiency was for all three enzymes 0.991 (95% confidence limits: 0.983-0.995) and for all three enzymes the discrimination value giving this efficiency was several times the upper limit of reference range: 1 779 micrograms/l for cathodic trypsin-like immunoreactivity, 831 U/l for pancreatic isoamylase and 316 micrograms/l for pancreatic lipase. None of the enzymes had any prognostic value at admission in predicting a mild or severe attack of acute pancreatitis. In conclusion, no single enzyme or combination of enzymes had any diagnostic advantage for acute pancreatitis in patients with acute abdominal pain. Thus selection of one of the three enzymes as diagnostic test of acute pancreatitis is to be based on considerations such as economy, methodological simplicity, possibility of automated assay and the time-consumption at the assay.

Volkmann's ischaemic contracture due to limb compression in drug-induced coma.

A case of Volkmann's contracture secondary to prolonged compression of the limb is presented. The events developed in a patient who had been comatose following an overdose of alcohol and a sedative drug.

Laparoscopic sterilization with the Falope-ring technique in the puerperium.

One hundred and forty-one women were planned to be sterilized by the Falope-ring technique after vaginal term delivery. Two pregnancies (1.55%) occurred during an average observation period of 43.2 months. Tearing of the mesosalpinx with bleeding requiring laparotomy occurred in 2 cases, and was the major operative complication seen. In 3 cases, laparotomy was performed because of reduced visual field caused by the enlarged uterus and in 2 cases because of technical problems with maintaining pneumoperitoneum. In 10 patients, hysterosalpingography was performed. In 2 cases leakage was demonstrated and these patients were readmitted to laparoscopic sterilization in the interval phase. One woman was admitted to the hospital with acute lower abdominal pain one year after sterilization; laparotomy showed the salpinx to be twisted three times around the ring. The Falope-ring technique is recommended as a safe, easy and quick method for sterilization in the puerperium.

Transcutaneous oxygen tension response to exercise in health and in occlusive arterial disease.

Transcutaneous oxygen tension (TcPO2) was measured on the foot at rest and during exercise in supine position in 21 clinically healthy controls and in 17 patients with intermittent claudication. All patients had ankle pressure greater than 50 mmHg and arteriographically proven peripheral vascular disease. Resting TcPO2 was significantly lower in the patient group than in the control group, though with considerable overlap between the groups. During exercise, however, TcPO2 showed highly significant decrease in the patient group. The median change following exercise in that group was -90% (range -54 to -100%) of the resting value. In the control group there was no significant fall in TcPO2 during 4 min exercise--median change -8% (range +30 to -34%). During exercise there was no overlap between the patient and the control group. Foot TcPO2 measurement during exercise in supine position is a simple, noninvasive and highly specific test for identifying patients with significant peripheral vascular disease.

Immunochemical qualitative latex agglutination test for pancreatic lipase in serum evaluated for use in diagnosis of acute pancreatitis.

In 417 patients (213 men, 204 women) consecutively hospitalized with acute abdominal pain we evaluated the clinical usefulness of a latex-agglutination test at admission to screen for concentrations of pancreatic lipase (EC 3.1.1.3) in serum greater than 300 micrograms/L. The diagnoses of acute pancreatitis (in 25 patients, 6%) and other diseases were made without knowledge of the results of the latex test or of quantification of pancreatic lipase in the serum by enzyme immunoassay. In the latex assay, when agglutination was taken as a positive test for acute pancreatitis, we found a diagnostic efficiency of 0.986 (95% confidence limits: 0.971-0.997) for acute pancreatitis. The predictive value of a positive latex test result with respect to acute pancreatitis was 0.807 (0.625-0.926); the predictive value of a negative test was 1.000 (0.991-1.000). Six patients had false-positive test results. No false-negative test results were found by enzyme immunoassay. We conclude that the latex agglutination test is useful as an emergency test for diagnosis of acute pancreatitis in patients with acute abdominal pain; negative results virtually exclude acute pancreatitis.

Primary suture of anorectal abscess. A randomized study comparing treatment with clindamycin vs. clindamycin and Gentacoll.

UNLABELLED: Gentacoll (Schering-Plough A/S, DK-3520 Farum, Denmark) implant is a biologically absorbable collagen with gentamicin, which enables local use of gentamicin in an abscess cavity. PURPOSE: To increase healing rate in treatment of perianal abscess with primary suture, the effect of intraoperative parenteral clindamycin and Gentacoll was investigated against monotherapy with intraoperative clindamycin in a randomized study. METHODS: One hundred seven patients, 55 in the Gentacoll group and 52 in the control group, were enrolled in the study and followed for three months. RESULTS: Twelve patients (22 percent) in the Gentacoll group developed a new abscess and/or fistula. In the control group nine patients (17 percent) developed a recurrent abscess or a fistula. In both groups 43 patients had an uneventful course. The differences between the two groups were not significant. Of all 107 patients, 19.5 percent had recurrent disease in the follow-up period. Duration of hospitalization and reconvalescence were identical in both groups. One case of superficial thrombophlebitis was seen after clindamycin. No other adverse effects to either Gentacoll or clindamycin were seen. CONCLUSION: The study shows that Gentacoll is a safe preparation but is without value as a supplement to clindamycin in the treatment of acute perianal abscess with primary suture. The study has documented the value of this treatment under cover with a intraoperative dose of clindamycin.

Immunity against tetanus and response to revaccination in surgical patients more than 50 years of age.

Several instances of fatal postoperative tetanus have been reported, and it has recently been stated that failure to secure adequate immunization for surgical patients may have medicolegal repercussions. In order to investigate according to which criteria for the immunization surgical patients can be considered protected, 178 patients who were more than 50 years of age and who were admitted electively during one year to two surgical departments were studied. To investigate immunity relative vaccination history, all patients admitted during the first two months were offered participation in this study. One hundred and twenty-seven (86 per cent) of these patients were studied by detailed registration of vaccination history and determination of antitoxin concentration in serum. Forty-seven per cent had never been vaccinated against tetanus and 67 per cent had antitoxin concentrations in serum below the protective level. To investigate in detail the duration of immunity and the effect of revaccination, patients with documented complete primary vaccination only were studied during the entire period. An additional 51 patients have been entered into the study during the last ten months. Antibody concentration in the serum corresponded to a continuous fall off in immunity after vaccination. Patients who had received a complete three dose primary vaccination within the last five years or a revaccination within the last ten years were well protected. Forty-four patients received revaccination during the study and were controlled by blood sample four weeks later. Every patient obtained satisfactory antibody concentrations, and it was concluded that no special requirements in recommendations for vaccination are needed, even for elderly patients. Thirteen patients who underwent extensive surgical procedures had serial blood samples taken every three days. Antitoxin concentrations in serum increased sigmoidally with time, and the slow initial increase suggested that revaccination should optimally be given some days before the operation to assure protection in the first few postoperative days.

Revaccination against tetanus 17 to 20 years after primary vaccination: kinetics of antibody response.

In 24 military recruits vaccinated against tetanus 17-20 years earlier antibody responses were studied 4, 11, and 24 days after revaccination. Antitoxin concentration in serum showed a sigmoid increase with titres at day 4 only just above protective level, corresponding to a risk of susceptibility to be expected even 4 days after revaccination (2.0%, 95% confidence limit). Only after 7 days the risk of unprotection was less than 1%. As the incubation period of tetanus can be as short as 24 hours, revaccination only may not be regarded sufficient if more than 17-20 years have elapsed since primary vaccination and conditions favoring rapid development of tetanus are present. The findings may explain some of the cases of tetanus which have occurred in spite of primary vaccination supplemented by emergency booster. The statement that prophylactic tetanus immunoglobulin is never indicated to persons completely vaccinated earlier should be considered for revision.

Revaccination of adults against diphtheria. II: Combined diphtheria and tetanus revaccination with different doses of diphtheria toxoid 20 years after primary vaccination.

Immunity following diphtheria vaccination in childhood is temporary, and recent outbreaks of diphtheria in adult populations evoked interest in the effect of and side-reactions to revaccination of adults. 237 military recruits were randomly allocated to revaccination with 6 Lf tetanus toxoid or 6 Lf tetanus toxoid combined with 2 Lf or 5 Lf diphtheria toxoid. Side-reactions were recorded one week later, and antitoxin response was assessed after 4 weeks. Protective serum diphtheria antitoxin levels were attained by all subjects receiving diphtheria toxoid containing vaccines. Antibody response was related to dose, indicating a safer long-term protection by revaccination with 5 Lf diphtheria toxoid. All vaccinees, except one without documentation for primary vaccination, attained high tetanus antitoxin levels. Interference phenomena between toxoids were insignificant. Mild local reactions were reported by 22% of the vaccinees. More pronounced local reactions were experienced by 5% and systemic reactions by 3%, independent of vaccine. No serious reactions were observed. Reactions were significantly related to tetanus antitoxin response only. It was concluded that combined revaccination of adults, primary vaccinated around 20 years previously, may be performed without immune assessments.