Vesa Perhoniemi

Rapid measurement of urinary trypsinogen-2 as a screening test for acute pancreatitis

BACKGROUND Acute pancreatitis can be difficult to diagnose. We developed a rapid dipstick screening test for pancreatitis, based on the immunochromatographic measurement of urinary trypsinogen-2. METHODS We prospectively compared the urinary trypsinogen-2 dipstick test with a quantitative urinary trypsinogen-2 assay, a urinary dipstick test for amylase, and serum and urinary amylase assays in 500 consecutive patients with acute abdominal pain at two emergency departments. Acute pancreatitis was diagnosed according to standardized criteria. RESULTS The urinary trypsinogen-2 dipstick test was positive in 50 of the 53 patients with acute pancreatitis (sensitivity, 94 percent), including all 7 with severe pancreatitis. Two patients with urinary trypsinogen-2 concentrations below the sensitivity threshold of the test (50 ng per milliliter) and one with a very high concentration had false negative results. The test was also positive in 21 of the 447 patients without pancreatitis (specificity, 95 percent), including 7 with abdominal cancers, 3 with cholangitis, and 2 with chronic pancreatitis. The sensitivity and specificity of the dipstick test were similar to those of the quantitative urinary trypsinogen-2 assay and higher than those of the urinary amylase dipstick test. The serum amylase assay had a sensitivity of 85 percent (with a cutoff value of 300 U per liter for the upper reference limit) and a specificity of 91 percent. The sensitivity and specificity of the urinary amylase assay (cutoff value, 2000 U per liter) were 83 and 88 percent, respectively. CONCLUSIONS In patients with acute abdominal pain seen in the emergency department, a negative dipstick test for urinary trypsinogen-2 rules out acute pancreatitis with a high degree of probability. A positive test usually identifies patients in need of further evaluation.

Catechol-O-methyltransferase activity in human and rat small intestine

The activities of soluble (S-COMT) and membrane-bound (MB-COMT) forms of catechol-O-methyltransferase in different regions of human and rat small intestine were determined. S-COMT was the predominant form both in the mucous membrane and in the muscle layers. The activity of S-COMT was more than twice as high in the mucous membrane as in the muscle layer. The activity of MB-COMT was almost equal in the different regions of the gut as well as in the mucous membrane and muscle layers. However, the ratio of the soluble form to the membrane-bound form was close to one in the human muscle layers of the jejunum and ileum.

Survival in operable non‐small‐cell lung cancer: Role of p53 mutations, tobacco smoking and asbestos exposure

Validated markers are needed to identify operable lung cancer patients with poor prognosis. About one‐half of non‐small‐cell lung cancers (NSCLCs) carry a mutation in the p53 tumor‐suppressor gene. We examined 101 NSCLC patients for surgical stage, completeness of resection, tobacco smoking, asbestos exposure, age, gender and p53 gene mutations as prognostic factors after a follow‐up period of 4 years. Cox`s multivariate regression model was applied to quantify the associations with overall and cancer‐related survival. Patients with a wild‐type p53 gene had an overall 4‐year survival of 43% and those with a mutated p53 gene, 35%. In squamous‐cell carcinoma, stage and heavy smoking, defined as the median of pack‐years smoked, had prognostic significance for overall survival. Only stage was associated with poor cancer‐related survival. Asbestos exposure was not associated with overall survival or cancer‐related survival in squamous‐cell carcinoma or adenocarcinoma. In adenocarcinoma, p53 mutation, in addition to stage, emerged as a significant predictor of poor cancer‐related survival. Int. J. Cancer 86:590–594, 2000.

Effects of Flunarizine and Pentoxifylline on Walking Distance and Blood Rheology in Claudication

Thirty-one patients, mean age 60 years (range 45-80 years), with a typical history and objective symptoms of intermittent claudication with a reported maximal walking dis tance less than 500 m, were included in a cross-over study. After a one months run-in period on placebo, the patients were randomized into two groups: one group started with flunarizine (5 mg t.i.d.) and the other with pentoxifylline (400 mg t.i.d.). The treatment lasted 3 months, whereafter the medications were changed. The trial followed a double-blind design. The median of the maximal walking distance was 255 m after the placebo period, increasing significantly (p<0.01) during both medication periods: by 43% and 18% during flunarizine and pentoxifylline, respectively. No changes were recorded in the ankle systolic blood pressure ratio (ASBP-ratio) after placebo or either medication period. Red cell rigidity (Pmax), which was initially elevated, decreased significantly (p<0.05) during both medication periods, but there were no significant differences between the two drugs. No changes were found in whole blood or plasma viscosity. We conclude that the decrease in red cell rigidity may have contributed to the increased walking distance.

Surgery for lung cancer in the elderly.

In order to assess the appropriateness of lung cancer surgery in the elderly and determine optimal subjects and resection procedure, 75 patients operated on in 1976-1996 at age > or =75 years (including 13 > or =80) were followed up. The operations included limited resection (8), lobectomy (47), bilobectomy (10) and pneumonectomy (10) and were judged to be radical in 59 cases (79%). Perioperative mortality was 9% and morbidity 29%, including 21% major complications. Cumulative 5-year survival was 32%, in stages IA-IIB 27-41%, and cancer-related survival 61-79%. Mortality did not differ significantly between resection types, but morbidity did. Nor did mortality, morbidity or survival differ between the age groups 75-79 and > or =80 years. In stage I cancer there was no significant difference in survival or cancer-related survival after lobectomy vs limited resection. We conclude that age, even >80 years, is not incompatible with curative resection. Lobectomy is the treatment of choice, but a less radical resection may be advisable if there is comorbidity. If more extensive resection is performed, the individual surgical risk must be weighed against the potential long-term benefit.

Long-term results of vein sparing varicose vein surgery

The aim of this study was to assess the long-term functional outcome of vein sparing varicose vein surgery using handheld Doppler ultrasound (HHD). The series consisted of 171 consecutive day-case surgery patients operated on for uncomplicated lower limb varicose veins. Venous segments considered competent were spared based on clinical examination and HHD, which was performed preoperatively only when deemed necessary by the surgeon. After a mean follow-up of 8 years all patients were examined, a systematic HHD evaluation was performed, and the findings were classified according to the CEAP (Clinical, Etiological, Anatomical, Pathophysiological) classification, and disability scoring was performed. During the follow-up period 17% of the legs were reoperated or scheduled for reoperation. At follow-up 79% of all patients were asymptomatic without reoperation. In 24%, recurrent varicosities were present and venous reflux was demonstrated by HHD. Recurrence was two times more common when the saphenofemoral junction had originally been left intact. Of all recurrent cases, reflux was demonstrated in the long saphenous vein (LSV) above the knee in 62%, in the LSV below the knee in 7%, in the short saphenous vein (SSV) in 16%, in the posterior arch vein in 38%, and in a thigh perforator in 8%. Of the legs reoperated during the follow-up period 41% presented with venous reflux at the follow-up visit. We conclude that HHD efficiently reveals sites of reflux that have been missed during previous surgery and that a thorough preoperative HHD examination and marking of reflux routes is required.RésuméLe but de cette étude a été d’évaluer l’évolution fonctionnelle à long terme de la chirurgie conservatrice pour varices des membres inférieurs en utilisant un appareil écho doppler (ED) tenu à la main. Notre série a consisté en 171 patients consécutifs traités en ambulatoire pour varices des membres inférieurs non compliquées. Tout segment de veine considéré comme compétant a été épargné, basé sur les données de l’examen clinique et l’ED, qui a été réalisée en préopératoire lorsque le chirurgien l’a estimé nécessaire. Après un suivi moyen de huit ans, tous les patients ont été examinés, une évaluation systématique par ED a été réalisée et les résultats ont été classés selon la classification «CEAP» et la classification de handicap physique. Pendant le suivi, une réopération a été effectuée ou programmée pour 17% des jambes. Au suivi, 79% de tous les patients étaient asymptomatiques sans réopération. Chez 24%, on a trouvé des varicosités récidivantes et on a mis en évidence un reflux veineux par l’ED. La récidive a été deux fois plus fréquente lorsque l’on a laissé intacte initialement la jonction saphéno-fémorale. Dans tous les cas de récidives, on a mis en évidence un reflux dans la saphène majeure (SMa) (interne) au-dessus du genou dans 62% des cas, dans la SMa en dessous du genou dans 7%, dans la saphène mineure (Smi) (externe) chez 16%, dans la communicante veineuse postérieure chez 38%, et dans une perforante de la cuisse dans 8%. 41% des jambes réopérés dans la période de suivi ont eu un reflux veineux lors de la visite de contrôle. Nous concluons que TED décèle effectivement les sites de reflux qui ont été méconnus lors de l’acte chirurgical antérieur et qu’un examen ED préopératoire complet avec marquages des veines de reflux est nécessaire.ResumenEl objectivo de este estudio fue averiguar los resultados funcionales tardios, mediante ecoangiografia Doppler (HHD), del tratamiento quirûrgico controlado (conservador) de las varices. Nuestra casuistica comprende 171 pacientes con varices simples del miembro inferior, intervenidas ambulatoriamente. Los segmentos venosos considerados compétentes, tanto por la exploración clínica corno mediante el HHD preoperatorio (si tal prueba diagnóstica era requerida por el cirujano) se respetaron. Tras un seguimiento medio de 8 años, todos los pacientes fueron reexplorados, se realizó además, una evaluación sistemática con el HHD y los resultados se expresaron de acuerdo con la clasificación CEAP y en relación a su grado de incapacidad. Durante el periodo de seguimiento el 17% de los casos fueron reintervinieron o estaban programados para una reoperación. Al finalizar el seguimiento, el 79% de todos los pacientes no habían requerido reopersción alguna y estaban asintomäticos. En el 24% había recidiva varicosa, con reflujo venoso demostrado mediante el HHD. Las récidivas se duplicaron cuando en la operación inicial se habÌa respetado la conjunción safeno-femoral. En todas las récidivas se constatò reflujo en la vena safena interna (LSV): por encima de la rodilla en el 62% y por debajo en el 7%; se registrò reflujo en la safena externa en el 16%, en el arco venoso posterior en el 38% y en las perforantes del muslo en el 8% de los casos. El 41% de los miembros reintervenidos durante el periodo de seguimiento presentaban, ya en la primera visita, reflujo venoso. El HHD muestra claramente los puntos de reflujo que pasaron desapercibidos durante la intervención quirúrgica inicial. Por consigliente, es preciso realizar, en todos los casos, un HHD preoperatorio para demarcar todas las posibles rutas de reflujo.

Successful treatment of mediastinal gas gangrene due to esophageal perforation

Esophageal perforation and mediastinal gas gangrene developed in a 55-year-old male after the endoscopic ethanol injection of a Mallory-Weiss ulcer. Initially, extensive gangrene of the esophagus and the mediastinum was treated by esophagectomy; however, an abundance of Clostridium perfringens in the Gram stain verified the presence of gas gangrene. Subsequently, the patient was transferred to a hyperbaric oxygen center, wherein a total of seven hyperbaric treatments were administered. The patient survived, and 4 months later, after having undergone several reoperations because of pleural empyema, mediastinal abscess, splenic rupture, and acalculous cholecystitis, was discharged and is still surviving.

Delayed Intrathoracic Herniation of the Stomach with Pleural Empyema Due to Diaphragmatic Stab Wound: Case Report

A 32-year-old man received a left-sided thoracic stab wound, which was primarily treated with percutaneous tube thoracostomy. Ipsilateral empyema appeared 8 weeks later and subsequent investigations revealed herniation of the stomach through the diaphragm. The diaphragmatic rupture and a perforation in the gastric wall were repaired at thoracotomy. The literature on such wounds is reviewed.

An alternative method for calculating changes in arterial calf blood flow at rest

SummaryIn 20 patients we studied the changes in calf arterial blood flow (AF) following spinal and epidural blocks, using venous occlusion strain gauge plethysmography (SGP). AF was calculated both in the conventional way by drawing a tangent to the initial upslope of the curve, and by a new method which measures the time to the point when 50% of venous capacity is reached (tVC50). The statistical differences within and between the spinal and epidural groups for AF and tVC50 were determined. In measuring the post-block changes in AF as compared with the control values, a statistically significant correlation (rs=−0.85, p<0.01) was observed between the two methods. We conclude that the new variable, tVC50, seems to be potentially useful in calculating changes in arterial blood flow at rest, and could be used, for example, in connection with surgical and pharmacological interventions, especially when the initial upslope of the SGP curve is equivocal.