Lisbeth Jørgensen

Proactive administration of platelets and plasma for patients with a ruptured abdominal aortic aneurysm: evaluating a change in transfusion practice

BACKGROUND: Continued hemorrhage remains a major contributor of mortality in massively transfused patients and those who survive have a higher platelet (PLT) count and a shorter prothrombin time and activated partial thromboplastin time (APTT) than nonsurvivors. It was considered that early substitution with PLTs and fresh‐frozen plasma (FFP) would prevent development of coagulopathy and thus improve survival.

Defective cerebrovascular autoregulation after carotid endarterectomy.

Correction of high grade carotid artery stenosis may result in cerebral hyperperfusion because of defective vascular autoregulation. Thus, transcranial Doppler was used to determine mean arterial flow velocity (Vmean) of the middle cerebral artery in 95 patients before and after carotid endarterectomy. Attention was focused on postoperative episodes of ipsilateral headache and hypertension. Symptoms of cerebral hyperperfusion lasted for 3 (1.5-5) h (median and range) in nine patients, and for 12 (8-14) days in nine other patients. Of these later patients, two developed seizures on the 5th and 6th postoperative day, respectively. The mean pressure difference across the stenosis was 31 (0-63) mmHg in the symptomatic group (n = 18) as opposed to only 10 (0-60) mmHg in the asymptomatic group (n = 77) (p < 0.01). In the 18 patients with headache after surgery, ipsilateral Vmean increased to 177 (130-332)% of the preoperative value (p < 0.0001), while the contralateral Vmean remained unchanged. After blood pressure was reduced in symptomatic patients with labetalol, ipsilateral Vmean decreased from 92 (69-124) to 56 (32-93) cm s-1 (p < 0.0001) as systemic arterial pressure decreased from 101 (80-128) to 88 (60-103) mmHg, with no change in contralateral Vmean. Normalisation of Vmean via reduction of arterial pressure ended episodes of headache and seizure in symptomatic patients. Thus, in patients who developed post-endarterectomy hyperperfusion, these findings clearly demonstrated that ipsilateral middle cerebral artery mean flow velocity was pressure dependent. This substantiates the hypothesis of defective autoregulation in the ipsilateral hemisphere after carotid endarterectomy, and in turn demonstrates an immediate cessation of symptoms with reduction of arterial pressure even in normotensive patients.

24-Hour Home Par Weighing Test Versus 1-Hour Ward Test In The Assessment Of Mild Stress Incontinence

Twenty‐three normal volunteers and 31 women admitted for stress or mixed incontinence underwent two 24‐hour home pad weighing tests. In the patients the test result was compared with the result obtained with the 1‐hour ward pad weighing test. Median pad weight gain was 4 g/24‐h, with an upper 99% limit of 8 9/24 h in normal women. The median urine loss was 17 g/24‐h in the patients. Eighteen (58%) patients were classified as incontinent according to the result of the 1‐h ward test, versus 28 (90%) according to the result of the 24‐h home test. There was no significant correlation between the result of the 1‐h test and the 24‐h test. In the patients, test‐retest analysis showed a significant variation in the result of the 24‐h test.

Transcranial Doppler for Detection of Cerebral Ischaemia During Carotid Endarterectomy

We evaluated transcranial Doppler sonography (TCD) for the detection of cerebral ischaemia during carotid endarterectomy in 30 male and 14 female patients with ipsilateral focal cerebro-vascular symptoms. Surgery was performed during halothane-nitrous oxide anaesthesia with moderate hypocapnia. Eight patients had a temporary shunt owing to contralateral occlusion or a stump pressure below 40 mmHg, and/or EEG flattening. Transcranial Doppler sonography was followed intra-operatively together with electro-encephalography (EEG), internal carotid artery (ICA) pressures and cerebral blood flow (CBF). Middle cerebral artery mean flow velocity (Vmean) was 38 (22-96) cm s-1 (median and range) and decreased during cross-clamping to 28 (10-60) cm s-1 (p less than 0.0001). After removal of the clamp it increased to 42 (20-102) cm s-1 (p less than 0.0001). AVmean clamp of less than 30 cm s-1 together with a Vmean clamp: Vmean pre-clamp ratio of less than 0.6 showed an accuracy with respect to CBF below 20 ml 100 g-1 min-1 of 89%. AVmeanclamp:Vmean pre-clamp ratio below 0.4 detected all all patients with EEG flattening (n = 3) (accuracy 97%). The corresponding level of accuracy obtained with stump pressure was 80%. The results indicate that middle cerebral flow velocity enables an increase in the accuracy of detecting cerebral ischaemia during carotid endarterectomy.

Clinical and pharmacokinetic evaluation of gentamycin containing collagen in groin wound infections after vascular reconstruction

Fourteen patients with localised groin wound graft infection after vascular reconstruction were included in this study to evaluate the clinical effect and the pharmacokinetic profile of gentamycin containing collagen for local antibiotic treatment. All patients were treated by surgical revision and the implantation of one collagen sponge containing 130 mg gentamycin in addition to systemic antibiotics. At follow-up (median 10 months, range 6-15 months), 13 of the 14 patients were cured with a patent reconstruction, giving a success rate in this series of 93%. The pharmacokinetic study showed a very high initial gentamycin concentration in wound fluid, which neatly exceeded the MIC values for most bacteria normally considered resistant to gentamycin. These high MIC values were sustained for 2 to 3 days. In conclusion, this study demonstrated a good clinical effect of gentamycin containing collagen with a high cure rate. In the wound fluid an initial high concentration of gentamycin was achieved which lasted for 2-3 days.

Doxepin in the treatment of female detrusor overactivity: a randomized double-blind crossover study

A total of 19 women with detrusor overactivity and associated symptoms completed a double-blind placebo-controlled crossover study of doxepin. All patients had previously failed to respond to conventional pharmacotherapy. Doxepin was given at bedtime in a single 50 mg. dose for the first 2 weeks and, if needed, the dose was increased with 25 mg. in the morning for the last week of the 3-week treatment period, which was followed by 2 weeks of washout before crossover. The preference for doxepin to placebo was statistically significant (p less than 0.01). Doxepin caused a significant decrease in the nighttime micturition frequency and the nighttime incontinence episodes (p less than 0.05). Urine loss at the standardized 1-hour pad weighing test decreased significantly during treatment with doxepin although statistical significance (p equals 0.07) was not obtained. Cystometric parameters (first sensation and maximum cystometric capacity) improved significantly during treatment with doxepin (p less than 0.06 and less than 0.04, respectively). Side effects were frequent but mild. Suggestions for use of this tricyclic antidepressant in women with detrusor overactivity and possible mechanisms of action are discussed.

Vaginal repair in female motor urge incontinence

Sixteen consecutive female patients with motor urge incontinence underwent vaginal repair operation. The patients were reevaluated after a mean follow-up of 37 months (range 8-72 months). Detrusor instability disappeared in only 31% of the patients after surgery which corresponds to the subjective and the objective cure rate. High pressure instability (contractions greater than or equal to 25 cm H2O) and/or a high instability index (greater than 1) were found to predict significantly a very poor prognosis. It is concluded that vaginal repair is an ineffective surgical procedure in patients with motor urge incontinence.

Bladder Distension in the Management of Detrusor Instability

In a 10-year period, 15 patients were treated with bladder distension because of urinary symptoms associated with detrusor instability. All patients had failed to respond to previous drug therapy. Ten patients had previously undergone surgical procedures for urinary incontinence, also without success. Five patients had repeated bladder distensions performed because of lack of improvement after the first procedure. Follow-up cystometry was performed in 14 cases. In all cases the instability was unchanged. Only one patient reported improvement in voiding symptoms. No complications were seen. With a success-rate of 6% (1 out of 15 patients) we do not recommend bladder distension with the present procedure as therapy for detrusor instability.

Verrucous carcinoma of urinary bladder

A seventy-five-year-old man with a four-month history of dysuria had a verrucous squamous carcinoma harbored within a bladder diverticulum. Whereas this low-grade malignancy occasionally develops in bilharzial specimens, its occurrence in schistosome egg-negative bladders is distinctly uncommon, having been the subject of only 1 previous case report.

Gentamycin beads in the treatment of localised vascular graft infection—long term results in 17 cases

Seventeen patients were treated by the implantation of gentamycin beads for localised Szilagyi type III prosthetic graft infection. Three patients had a pan prosthetic infection and half of the remaining patients were cured, but three of these died from other causes within 3 months. The mean observation time of the four survivors was 20 months (7-39 months). One of the seven patients, in whom the gentamycin beads failed, died of infection, giving a total mortality rate of 6% (1.5-29%). The remaining patients were cured after resection of the infected segment of the prosthesis at a mean follow-up of 22 months (8-37 months).