[Referrals to clinical mammography in a county without screening program]. / Henvisningsmønsteret til klinisk mammografi i et amt uden screening.

Systematic mammography-screening may reduce the number of unindicated diagnostic mammographies. Six thousand, eight hundred and four women from Rosklde County underwent mammography at the Roskilde County Hospital over a four-year-period. Five hundred and nineteen women were excluded from the study, leaving 6285 women to form the study population. Twenty-four percent of the women had no clinical indication for mammography, 15% of the women had an increased risk of breast cancer, and for 61% of the women there was a clinical indication for mammography. Breast cancer was found in 0.46% of the women undergoing mammography without a clinical indication, in 1.2% of the women belonging to risk-groups, and in 8.9% of the women with a clinical indication for mammography. Biennial screening for breast cancer of 15,394 women (7697 women a year) in the age group 50-69 years could reduce the number of diagnostic mammographies by 338 women a year. Cooperation with GPs in a reduction of unindicated clinical mammographies of women younger than 50 years could reduce the number by a further 171 women. Potential savings in the X-ray-departments is not a weighty argument in favour of introduction of mammography screening.

Renal stones and primary hyperparathyroidism: natural history of renal stone disease after successful parathyroidectomy.

The aim of the study was to evaluate the risk of renal stone recurrence after successful surgical treatment of primary hyperparathyroidism (pHPT). Of 297 consecutive patients with surgically verified pHPT, 151 patients had had renal stone disease; a total of 113 patients were eligible for follow-up; and of these, 107 patients remained normocalcemic during follow-up and formed the study group. The number of new stones were calculated by subtracting the stones present on preoperative urograms from the number of stones on urograms after 1, 3, and 5 years and the number of stones passed or eliminated by intervention. Among 107 patients, 32 (30%) formed one to four new stones within 5 years. This recurrence rate is comparable to the expected recurrence rate in idiopathic stone formers. Primary hyperparathyroidism and renal stone disease are common. As all renal stone formers are screened for pHPT by serum calcium analysis, the two diseases might by coincidence be found in the same patients. A considerable number of patients with pHPT and renal stone disease therefore experience recurrence of their stone disease irrespective of the presence of normocalcemia after successful parathyroidectomy.

[CT of Achilles tendons]. / CT af akillessener.

Until recently, direct imaging of the Achilles tendon has been proved difficult. CT scanning was performed in three patients with Achilles tendon pain. The authors find that CT scanning is of diagnostic value but further experience is required.

Anomalous inferior vena cava impeding implantation of aortobifemoral vascular prosthesis.

A case of double inferior vena cava (IVC) impeding surgery of the abdominal aorta is presented. The patient also had duplication of the kidney and ureter on both sides. The anatomical anomalies of the IVC, kidney and ureter interfering with abdominal aortic surgery are reviewed.

Long-term results of Marmor arthroplasty in varus osteoarthritic knees.

Twenty-one osteoarthritic knees with an average varus angulation of 13 degrees were followed up for 7-10 years after resurfacing with the Marmor compartmental knee arthroplasty. There were 14 unicompartmental and 7 bicompartmental replacements, a total of 28 implants. The knees were assessed clinically according to the Hospital for Special Surgery knee rating scale. At the latest follow-up, 19 of these cases were still excellent or good. None of the knees had been corrected by more than the tightness of the ligaments allowed, and a varus inclination of an average of 2 degrees remained after operation and at the latest follow-up. Radiolucency of more than 2 mm around the tibial component was found in 2 out of 28 of the cases, but this was not associated with pain or disability, nor was wire breakage, found in 6 out of 28, or positional changes of the tibial component, which were seen in five patients. It is concluded that the Marmor compartmental knee arthroplasty is still indicated in osteoarthritic varus knees.

CBF before and after extracranial-intracranial bypass surgery in patients with ischemic cerebrovascular disease studied with 133Xe-inhalation tomography.

Cerebral blood flow (CBF) was studied by 133Xenon inhalation tomography in 22 patients with symptoms of ischemic cerebrovascular disease before and after establishment of an extracranial-intracranial bypass shunt. Selection of patients for shunting was based on angiographically demonstrated arterial occlusions and on the finding of focal low flow areas corresponding to the clinical symptoms, that consisted mainly of minor stroke with good remission and with or without subsequent TIAs. It was required that the area of low flow should clearly exceed the CT lesion present in practically all cases. Following surgery, the permanent neurologic deficits remained unchanged, while the TIAs stopped in all but one case. Two patients showed a definite increase of CBF in the low flow area while another two showed a questionable increase. All the other cases, 18 of the 22, showed an unchanged tomographic flow map with no trend towards diminution in extension or severity of the focal hypoperfused area. A persistent low flow in areas with no corresponding CT lesion following alleviation of a possible flow impediment is interpreted to represent an incomplete infarction or diaschisis.

Bone lesions in early syphilis detected by bone scintigraphy.

We report a case of early syphilis with multiple bone lesions which all resolved after treatment with penicillin. We discuss why bone lesions may be more prevalent than generally believed and why 99m-Tc-MDP-bone scintigraphy is more sensitive than radiography in detecting syphilitic periostitis.

Crossed cerebellar diaschisis in ischemic stroke: a study of regional cerebral blood flow by 133Xe inhalation and single photon emission computerized tomography.

Seventy measurements of CBF were performed in 12 stroke patients by 133Xe inhalation and a rapidly rotating single photon emission computerized tomograph. CBF was measured every other day during the acute phase and at 2- and 6-month follow-up visits. A persistent contralateral cerebellar blood flow depression was evident in five patients with severe hemispheric low flow areas, which correlated with large, hypodense lesions on the computerized tomographic scan. In a sixth patient with a small, deep infarct, a transient crossed cerebellar low flow was observed, while the clinical symptoms persisted. It is concluded from this serial study that crossed cerebellar diaschisis is a common finding in completed stroke. It is probably caused by disconnection of the corticopontine pathways, a disconnection that tends to persist. The phenomenon is in fact less variable than the stroke-related CBF changes in the infarcted hemisphere, in which a period of relative hyperemia is frequently seen.

Hemodynamically significant stenosis of the internal carotid artery treated with endarterectomy. Case report.

Repeated cerebral blood flow (CBF) measurements with xenon-133 inhalation and single photon emission tomography were performed in a patient suffering a minor stroke with subsequent orthostatic-provoked transient ischemic attacks (TIA's). Angiography revealed a thread-like internal carotid artery and an occluded external carotid artery on the side of the ischemic neurological symptoms. Computerized tomography and technetium-99m-pertechnetate brain scintigraphy 2 weeks after stroke were both normal. Before reconstructive vascular surgery, resting CBF showed a hypoperfused area corresponding to the clinical symptoms. Diamox (acetazolamide, 1 gm) increased CBF by 24% in the unaffected hemisphere, whereas even a slight decrease in flow ("steal") was seen in the maximally affected region. In contrast, theophylline (220 mg) reduced CBF in the unaffected hemisphere and caused a slight increase in the previously maximally hypoperfused area ("inverse steal"). After surgery, the flow pattern practically normalized and the TIA's disappeared. The CBF measurements before surgery and also after the injection of the vasoactive drugs indicated that focal hemodynamic insufficiency elicited the TIA's, and pointed at a low mean arterial blood pressure of about 35 mm Hg in the affected hemisphere. The perioperative finding of a mean blood pressure in the internal carotid artery of 31 mm Hg on the symptomatic side confirmed that the brain tissue had a severely reduced perfusion pressure. On clamping the artery, a stump pressure of 22 mm Hg and electroencephalogram flattening was noted, so a temporary internal shunt was inserted. The findings demonstrate that preoperative CBF measurements, including studies of the regional vasoreactivity, may identify patients with hemodynamic TIA's. These patients are at particular risk of developing cerebral ischemia during carotid endarterectomy, as any further compromise of the inflow may precipitate frank ischemia.

Serial measurement of regional cerebral blood flow in patients with SAH using 133Xe inhalation and emission computerized tomography.

A noninvasive three-dimensional method for measuring cerebral blood flow (CBF), xenon-133 inhalation and emission computerized tomography, was used to investigate the CBF changes accompanying delayed neurological deterioration following subarachnoid hemorrhage (SAH). A total of 67 measurements were performed on 20 patients in Hunt and Hess' clinical Grades I to III in the first 21 days post SAH. Five patients with normal CBF tomograms on admission developed delayed neurological deficits in the 2nd week after hemorrhage, at which time repeat CBF tomograms in four patients revealed large areas of well defined regional flow decrease in the vascular territories of the anterior or middle cerebral arteries. Severe vasospasm was noted in three of these patients in whom arteriography was performed in the 2nd week post SAH. Diffuse bihemispheric CBF decreases were noted later in the course of delayed neurological deficits; however, measurements obtained soon after the onset of focal symptoms suggest that the only CBF decreases directly produced by vasospasm in Grade III patients are regional changes.

Regional cerebral blood flow in patients with transient ischemic attacks studied by Xenon-133 inhalation and emission tomography.

Cerebral blood flow CBF was studied in 14 patients with transient ischemic attacks TIA and arteriosclerotic neck vessel disease. CBF was measured by a rapidly rotating single photon emission computerized tomograph using Xenon-133 inhalation. This method yields images of 3 brain slices depicting CBF with a spatial resolution of 1.7 cm. Based primarily on the clinical evidence and on the angiographical findings embolism was considered the pathogenetic factor in 10 cases, whereas chronic hemodynamic insufficiency rendered symptomatic by postural factors probably accounted for the symptoms in 4 patients. Of the 14 patients, all studied days to weeks after the most recent TIA, four showed hypoperfused areas on the CBF-tomograms and with roughly the same location hypodense areas on CT-scanning, i.e. areas of complete infarction. However, an additional five patients showed reduction of CBF in areas with no abnormality on the CT-scan. The abnormal blood flow pattern was found to be unchanged after clinically successful reconstructive vascular surgery. This suggests the presence of irreversible ischemic tissue damage without gross emollition (incomplete infarction). It is concluded, that TIAs are often harmful events, as no less than 9 of the 14 patients studied had evidence of complete and/or incomplete infarction. Thorough examination and rational therapy should be instituted as soon as possible to prevent further ischemic lesions.

The iliac vein compression syndrome. A case report with a review of the literature.

The iliac compression syndrome results from reduced venous return from the left leg due to pressure from the right common iliac artery on the underlying left common iliac vein where it enters the inferior vena cava. The pressure results in intravenous band and adhesion formation which can lead to iliofemoral thrombosis with insufficient recanalization. We present such a case in a young man who had swelling, venous claudication, siderosclerosis, and skin ulcers. The syndrome was diagnosed by pelvic phlebography, arteriography, venous emptying time, and venous pressure measurement. Palma's crossover operation was performed, in which the contralateral great saphenous vein was transposed subcutaneously to the ipsilateral common femoral vein peripheral to the obstruction. To avoid graft thrombosis, a temporary arterio-venous fistula was created. Follow-up six months after the operation showed the operative result to the satisfactory.

Infradiaphragmatic arteriosclerosis in the 5th decade: an angiographic comparison between sexes.

Ninety consecutive arteriographies performed on patients in the age group 40-50 years (45 men and 45 women) because of signs and symptoms of peripheral vascular disease were analyzed for severity and distribution of obliterative or occluding arterial lesions. A marked difference in the arteriosclerotic pattern was found between the two sexes. Women presented with aortoiliac changes and slight peripheral changes, while men more frequently had severe peripheral changes and few severe aortic changes. In 22 premenopausal and 23 postmenopausal women there was no difference in the localization or degree of the arteriosclerotic changes. It was not possible to draw conclusions from gynecological-obstetrical information. In this study all but six patients were smokers, but no differences in the extent of arteriosclerotic changes were observed between the heavy smokers and the other patients.

Hydroxychloroquine sulphate in prevention of deep venous thrombosis following fracture of the hip, pelvis, or thoracolumbar spine.

One hundred and fifty-three patients, forty-eight to ninety-seven years old, were included in a double-blind placebo-controlled investigation of the usefulness of hydroxychloroquine sulphate for the prevention of deep venous thrombosis in patients with fractures of the hip, pelvis, or thoracolumbar spine. The results indicated that this drug can reduce the number of thrombeombolic complications significantly (p less than 0.005), a finding that corresponds to the results obtained with other drugs such as coumarin derivatives or dextran 70.

Small heparin doses as prophylaxis against deep-vein thrombosis in major surgery.

100 patients were treated either with heparin 5,000 i.u. every 12 hours or placebo in a double-blind, randomized, prospective trial. The treatment was commenced 1-3 hours before surgery and was continued for 6 1/2 days. The criteria for the selection of patients and the principles on which the treatment and investigation schedules were based corresponded generally to those laid down by Kakkar et al. (1972). The incidence of deep-vein thrombosis of the lower extremities was 6% in the group treated with heparin and 20% in the placebo group. The decisive diagnosis of thrombosis was based on the scanning of the lower extremities after administration of I125-fibrinogen. No case of pulmonary embolism occurred and no complications because of the treatment were noted. We propose to institute investigations on a larger scale to evaluate the prophylactic value of small heparin doses with respect to pulmonary embolism.