Amniotic fluid erythropoietin correlates with umbilical plasma erythropoietin in normal and abnormal pregnancy.

In the human fetus, elevated plasma erythropoietin levels have been found in high-risk pregnancies at delivery. We examined the relationship of amniotic fluid erythropoietin and umbilical plasma erythropoietin at delivery in 17 normal pregnancies, 41 hypertensive pregnancies, and 37 insulin-treated diabetic pregnancies terminated by elective cesarean section without labor. An additional 27 insulin-treated diabetic patients were studied after undergoing variable durations (86-1184 minutes) of labor. Erythropoietin was analyzed using a highly sensitive and specific radioimmunoassay technique. Fetal plasma erythropoietin concentrations were elevated above the control upper range (50.3 mU/mL) in 59% of the hypertensives and in 38% of the diabetics. The amniotic fluid erythropoietin values were significantly lower than the umbilical plasma erythropoietin values in each study group. Although the umbilical plasma erythropoietin values in the abnormal pregnancy groups differed considerably from the corresponding levels in the controls, the ratio of amniotic fluid erythropoietin to umbilical plasma erythropoietin was approximately the same in controls, hypertensives, and diabetics. Furthermore, the plasma and amniotic fluid levels (In transformed) correlated highly significantly in all three individual groups in absence of labor. In the diabetic labor group, this relationship was nonsignificant. We conclude that in the absence of labor, amniotic fluid erythropoietin reflects fetal plasma erythropoietin. We speculate that amniotic fluid erythropoietin may be an antepartum indicator of fetal hypoxemia.

Minimally invasive coronary artery bypass grafting using the right gastroepiploic artery.

BACKGROUND: Anastomosis of the left internal thoracic artery to the left anterior descending artery without sternotomy and without cardiopulmonary bypass is a standard approach in minimally invasive coronary artery bypass grafting. To expand the indications for minimally invasive coronary artery bypass grafting from one-vessel disease to two-vessel disease, we began to perform anastomosis of the right gastroepiploic artery (RGEA) to the right coronary artery (RCA). METHODS: From February to November 1996, an RGEA graft was used in 25 of the 100 patients who underwent minimally invasive coronary artery bypass grafting at our clinic. Eleven of the patients had only RCA disease and 14 had both RCA and left anterior descending artery disease. One of the operations was a redo coronary artery bypass grafting. The RGEA was anastomosed to the RCA through a laparotomy incision and the left internal thoracic artery was anastomosed to the left anterior descending artery through a left anterior thoracotomy. In 5 patients, the RGEA was lengthened by venous grafting. RESULTS: All patients underwent angiography after operation; 82.6% of the RGEA grafts and all the left internal thoracic artery grafts were functioning well. In three of the four nonvisualized RGEA grafts, the percentage of proximal stenosis of the RCA seen on postoperative angiography was not critical (40%, 50%, and 50%, respectively), allowing significant competitive flow through the native bypassed RCA. The patency of all the RGEA grafts without competitive flow was 95%, with a 95% confidence interval of 75.1% to 99.9%. CONCLUSIONS: The indications for minimally invasive coronary artery bypass grafting could be extended to primary operations in patients with left anterior descending artery and RCA lesions by using both the left internal thoracic artery and the RGEA.

Prognosis after lymph node recurrence in papillary thyroid carcinoma depends on age.

Papillary thyroid carcinoma (PTC) is a malignancy that has good prognosis especially among patients up to 45 years of age; about half of the patients are female and of childbearing age. Lymph node recurrence (LNR) occurs in 10%-14% of patients but is considered to be associated with relatively good prognosis. The purpose of this study was to estimate the association between patient age at primary operation, and the behavior of the disease after LNR. Between 1967 and 1994, 495 patients underwent surgery for primary PTC at the Department of Surgery, Helsinki University Central Hospital. There were 391 (79.0%) women and 104 (21.0%) men with a mean age of 44.5 years (range, 10.8-85.4 years). Fifty-eight patients in whom LNR was the first clinical sign of persistent disease after complete clinical response to primary treatment were included in this series. At the time of primary operation, 37 (64.3%) of the 58 patients who developed LNR were younger than 45 years of age and 21 patients were older. The mean times to LNR in these groups were 42.0 months (range, 3.0-194.5 months) and 49.0 months (range, 3.6-209.0 months) respectively. Carcinoma-specific 5-year survival after LNR was 100% (95% confidence interval [CI] 88.8%-100.0%) in patients ages up to 45 years and 61.1% (40.5%-82.8%) in older patients; 10-year survival rates were 100%, and 41.3% (p < 0.0001), respectively. Relative survival at 10 years was 98.6% for patients ages up to 45 years and 42.6% for older patients (p = 0.0014). Using the Cox model it was shown that development of LNR after primary treatment has an independent highly significant negative effect on survival (p < 0.001) in patients over 45 years of age. Prognosis of PTC even after LNR on patients ages up to 45 years at the time of the primary operation is almost parallel to the normal reference population, but in patients over 45 years of age the prognosis is relatively poor.

Ultrasonically activated shears in thyroid surgery.

BACKGROUND: Ultrasonically activated shears (UAS) have been documented to be both safe and fast devices in laparoscopic surgery. We studied whether the use of UAS would have some advantage in thyroid surgery. METHODS: Thyroidectomies, performed by one senior endocrine surgeon between December 1996 and February 1997, were retrospectively matched, with patients operated on by the same surgeon using the conventional method. RESULTS: Six pairs of total thyroidectomies and one pair of lobectomies could be matched. Mean operating time was 100 minutes for the patients operated on with the UAS and 154 minutes for the patients operated on with the conventional method. The mean operating time with the UAS was thus on average 64.6% of the operation time with the conventional method, with a 95% confidence interval from 50.1% to 83.5% (t = 4.00, 6 df, P = 0.007). CONCLUSIONS: In this material the use of UAS reduced significantly operating time in thyroidectomies.

Effect of injection speed on the spread of ethanol during experimental liver ethanol injections.

RATIONALE AND OBJECTIVES: Percutaneous ethanol injection therapy may cause serious complications, most likely due to the uncontrolled spread of ethanol. The authors changed the speed of the injection into postmortem pig livers and examined the adverse spread of ethanol from the injection site and the shape and size of the resulting lesion. METHODS: One milliliter of 96% ethanol was injected into pig livers under sonographic guidance at different speeds (0.075-0.91 mL/s). The spread (graded from I to III) and the volumes and shapes of the resulting lesions seen after dissection were recorded and correlated with the injection speed. RESULTS: When increasing the speed of the injections the large, grade III spread increased significantly (P < .01). The lesions created by more rapid injection were less spherical than were those created by slower injections (P = .08). The volumes of the lesions were not affected by the injection speed. CONCLUSION: This experimental model suggests that in percutaneous ethanol injection therapy, rapid injection (> 0.3-0.4 mL/s) should be avoided to reduce the uncontrolled spread of ethanol. Spherical spreading of ethanol around the needle tip is best achieved with slow injection.

Analysis of triacylglycerols by silver-ion high-performance liquid chromatography-atmospheric pressure chemical ionization mass spectrometry.

Triacylglycerols of the seed oils rich in alpha- and/or gamma-linolenic acid moieties were separated by silver-ion high-performance liquid chromatography (HPLC) followed by on-line atmospheric pressure chemical ionization-mass spectrometric (APCI-MS) detection. Mass spectra of most triacylglycerols exhibited abundant [M + H]+ and [M - RCO2]+ ions, which defined the molecular weight and the molecular association of fatty acyl residues of a triacylglycerol, respectively. Silver ions formed weaker complexes with triacylglycerols containing gamma-linolenic acid than with those containing alpha-linolenic acid, i.e., the elution order of molecules was XYT gamma > XYT alpha, XT gamma T gamma > XT gamma T alpha > XT alpha T alpha, and T gamma T gamma T gamma > T gamma T gamma T alpha > T gamma T alpha T alpha > T alpha T alpha T alpha, where T alpha = alpha-linolenic acid, T gamma = gamma-linolenic acid, and X, Y = fatty acids different from linolenic acid. Furthermore, silver-ion HPLC resulted in partial separation within equally unsaturated triacylglycerols according to differences in the combined number of acyl carbons. Regioisomeric forms of triacylglycerols were not determined from the seed oil samples, although differences were measured with reference compounds in the relative abundances of [M - RCO2]+ ions formed by a loss of a fatty acyl residue from the sn-2 position and the sn-1/3 positions. Silver-ion HPLC/APCI-MS provided valuable information for structure elucidation of seed oil triacylglycerols: 43 molecular species were identified from cloudberry seed oil, 39 from evening primrose oil, 79 from borage oil, 44 from alpine currant, and 56 from black currant seed oils. The quantitation requires to be studied further, especially in those cases where several molecular weight species of triacylglycerols eluted in a single chromatographic peak.

Accelerated tissue expansion with the "overfilling" technique.

Temporary overexpansion of the tissues at each filling session increased the actual inflation volume by about 59 percent. This shortened the process of tissue expansion considerably. "Overexpansion" means that the pressure in the expander is increased to a point where the dermal capillary flow is zero or the patient experiences so much discomfort that inflation cannot be carried out any further. The pressure in the expander is thereafter gradually decreased by taking out saline until both the capillary refill and all other clinical criteria are sufficient for safe dermal circulation. Comparison of the expander volume at the final pressure to the initial filling volume at the same pressure before the "overfilling" confirmed an average gain of about 59 percent in 14 patients.

Tissue expander injection dome leakage.

Injection dome leakage was found to be the cause for partial disappearance of the saline solution injected into some tissue expanders. When the injection domes of 22 consecutively removed tissue expanders were checked, we found that the average leakage pressure of these was 32 mmHg, with a range of 8 to 110 mmHg. When the patients were lying on their expanders, the weight of the corresponding body part caused intraluminal pressures of up to 90 mmHg in their expanders. Following removal of the expanders, the total leakage was calculated quantitatively and found to be maximally over 50 percent of the injected volume in some instances. The leakage flow through the injection dome in seven consecutively removed expanders was checked at pressures of 25, 50, and 75 mmHg over 30 minutes and was found to be slow. The possibility of injection dome leakage should be kept in mind, however, as a potential complication under unfavorable conditions. At the same time, we want to emphasize that in most instances tissue expanders function quite well and in predictable ways.

Validity of laser Doppler flowmetry for measuring the effect of the tissue expander pressure on skin circulation. Simultaneous measurement of tissue pressure and laser Doppler flowmetry.

Intermittent Laser Doppler Flowmetry (LDF) was used in five patients to measure changes in the dermal blood flow when changing intraluminal pressures in tissue expanders (TE). In another patient, continuous monitoring of the intraluminal pressure in the TE and simultaneous LDF was used. Our finding is that LDF is a suitable method for the registration of reactions in dermal circulation, caused by TE pressure changes. A statistically significant association between the changes of the LDF values and the intraluminal pressure in the TE was observed.

[Assessment of construct and content validity of Monitor--an index of the quality of nursing care--and the evaluation of clarity and concreteness of the criteria of Monitor]. / Monitor--hoitotyön laadun arviointimittarin soveltuvuus hoitotyön laadun arviointiin Suomessa.

The purpose of this study was to test construct and content validity of Monitor and to evaluate if its criteria were clear and concrete. The construct validity was evaluated after reviewing the Finnish nursing literature in order to determine how man is perceived and what are the essential principles of Finnish nursing care. Each of the Monitor criteria was then compared with that view of man and the principles present in the literature. The human needs by Yura and Walsh were examined in order to find out to what extent the Monitor-instrument covers these needs. The content validity and the clarity and concreteness of the criteria were evaluated by experts. The results imply that the physical characteristics of man were prevalent in 76 out of 155 criteria. The essential principles were found in Monitor, but the principles concerning health centricity and patients' independence were found only in 13 out of 155 criteria. The instrument covered 4 human needs by Yura and Walsh totally and 20 in part. The experts rated 151 criteria content valid, 143 concrete and 139 clear in this study. Retesting is needed in the future studies.

[Family caregivers' expectations of respite care of patients with dementia]. / Dementoituvan ihmisen hyvä hoito--omaisen odotukset hoidon laadun kehittämisen perustana.

The aim of this study was to describe the family caregivers' expectations of the respite care of demented patients. The data was collected using structured theme interviews. The participants (n = 15) of this study were family members of patients suffering from moderate or severe dementia. The family caregivers used respite care as a mode of support either regularly or occasionally. The data was analyzed using content analysis and classified in categories based on the theoretical frame of the study. The results imply that family caregivers expect information concerning dementia, its causes as well as care possibilities. Above all the family caregivers expressed the need to know about the existing support services: domestic help, day care or respite care, voluntary nursing services etc. Also the severe need for psychological support was revealed. Family caregivers wished to have more opportunities to discuss the oppressive matters with the nursing staff. Health professionals need to know more about the family members as well as their expectations and perceptions. That enables them to intervene more effectively to ease the burden of adjustment and facilitate the continuous involvement in care.

[Quality assurance today and some future perspectives]. / Laadunvarmistus tänään, huomenna.

The purpose of this article is to describe the developmental level of QA in Finland. Working unit, regional and national level QA activities are reflected. The major effort to study the current situation of nursing QA was taken by STAKES (The National Research and Development Centre for Welfare and Health) in the beginning of 1993. Over 1200 institutions received a questionnaires where their QA activities were inquired. The increasing need for multiprofessional cooperation, better information and participation of nursing care personnel are discussed. To utilize research findings and to increase resources and skills of nursing care personnel to perform small scale studies are seen essential for QA advancement. To receive good quality care is a right of all patients. The nursing care personnel is responsible to deliver that kind of care. QA is a means to provide it. Accountability is demanded by both public and profession itself. Nurses have taken the leadership in providing good quality nursing care.

Ultrasonically activated shears in thyroidectomies: a randomized trial.

OBJECTIVE: To test whether the advantages of the ultrasonically activated shears (UAS) observed in thyroidectomies in a previous matched-pair study could be repeated in a randomized trial. SUMMARY BACKGROUND DATA: The UAS has been documented, mainly in nonrandomized studies, to be a safe and fast device in video-assisted and conventional surgery. METHODS: Thyroidectomies and lobectomies performed for benign or malignant thyroid disease between August 1997 and January 1999 were included in this series. Separate randomization, resulting in four sets of envelopes, was done for one consultant endocrine surgeon and for senior residents for both lobectomies and for total thyroidectomies. The operations performed with the UAS were compared with operations performed with the conventional method, using ligatures as the main hemostatic method. Main outcome measures were operating time, postoperative serum calcium level, palsy of the recurrent laryngeal nerve, and amount of intraoperative and postoperative bleeding. Possible bias that could have been caused by imbalance between treatment groups for surgeon experience was tested by two-way analysis of covariance. RESULTS: Thirty-six patients were randomized, 19 to the UAS and 17 to the conventional group. Mean operating time was 99.1 minutes in the UAS group and 134.9 minutes in the conventional group. The average savings in operating time with the UAS was thus 35.8 minutes. There was no difference in complications between the groups. The estimated savings in operating time would have been 1.66 times that observed in this study if the groups had been unbalanced with reference to surgeon experience. CONCLUSION: The UAS is a usable device in total thyroidectomies and lobectomies.

Job enrichment, work motivation, and job satisfaction in hospital wards: testing the job characteristics model.

This study investigated work motivation and job satisfaction at hospital wards with high and low levels of job enrichment. Primary nursing was assumed to represent a highly enriched job, whereas functional nursing represented a job with a low level of enrichment. Five surgical wards were divided into these two categories based on the structured interviews with head nurses. Work motivation and job satisfaction among ward personnel were assessed by a questionnaire. The ward personnel occupying highly enriched jobs reported significantly higher work motivation and satisfaction with the management than the personnel occupying jobs with a low level of enrichment.

Recovery of anal sphincter function following transabdominal repair of rectal prolapse: cause of improved continence?

Twenty-eight patients with complete rectal prolapse underwent anorectal manometry before and 6 months and 1-2 years after abdominal rectopexy and sigmoid resection in a study of the mechanisms responsible for postoperatively improved anal continence. Preoperatively, 22 patients reported defective and control. Seven patients (all with minor incontinence) regained normal control and eight other patients achieved improved continence after surgery. Anal resting, squeeze, and voluntary contraction pressures were significantly lower for defective than for normal control, with a significant rise in these pressures at 6 months after the operation, except for those incontinent patients in whom continence was not improved. No further pressure rise was seen later. Improvement of continence was not accompanied by changes in rectal sensation or reflexive functions of the internal anal sphincter. These results suggest that recovery of the resting and voluntary contraction functions of the sphincter muscles was the cause of continence improvement observed after surgery. Anal manometry was unable to predict outcome of function. Therefore, supplementary procedures for restoration of continence are not advisable, although patients with only minor incontinence are likely to regain full continence after rectopexy alone.

Estimation of fetal shoulder width by measurement of the humerospinous distance by ultrasound.

The present study was undertaken to find a practical method for estimating the fetal shoulder width by ultrasound. Sixty pregnant women at term were included in the study. The distance between the lateral margin of the fetal cartilaginous caput humeri and the processus spinosus of the cervical vertebra C7 (humerospinous distance) was measured by ultrasound. The neonatal shoulder width was measured with a craniometer during the first postnatal day. Linear regression analysis was used to calculate the correlation between the humerospinous distance and the shoulder width, and a significant linear correlation (r = 0.612, p < 0.001) was shown. Although, in this small study, we could not show a relationship between humerospinous distance and dystocia, we feel a clinical study of humerospinous distance as a predictor of shoulder dystocia is indicated.

Indications for early mandatory laparotomy in abdominal stab wounds.

BACKGROUND: Patients with an abdominal stab wound presenting with shock, peritonitis or evisceration are usually subjected to early laparotomy, although very few studies have been done to validate the criteria. METHODS: In a retrospective study of 209 consecutive patients with stab wounds of the anterior abdomen, flank or lower chest, 23 clinical and radiological criteria were evaluated for their accuracy in predicting the presence of significant abdominal organ injury. RESULTS: Overall, 89 patients (43 per cent) had a significant abdominal injury. The criteria with the highest positive predictive values for significant injury were: signs of continuing haemorrhage in initially normotensive patients (86 per cent), shock on admission (83 per cent) and generalized peritonitis (81 per cent). No positive direct or indirect signs of peritoneal penetration including omental evisceration, extraluminal air on plain radiography, or free peritoneal fluid on abdominal ultrasonography were independent predictors of significant injury. CONCLUSION: Signs of major internal haemorrhage or generalized peritonitis are reliable criteria by themselves for early laparotomy. Peritoneal penetration is a poor indicator of significant organ injury and warrants direct organ-specific evaluation, such as computed tomography or laparoscopy, to identify patients who can safely be treated without operation.