Three-year evaluation of late breast reconstruction with a free transverse rectus abdominis musculocutaneous flap in a county hospital in Sweden: a retrospective study.

We present our three-year experience of late breast reconstruction with conventional free TRAM flaps in 16 consecutive patients in a Swedish county hospital. The breast reconstruction was done unilaterally in 14 and bilaterally in two, giving a total of 18 free TRAM flaps in 16 patients. Six patients developed anastomotic or systemic thromboembolic events during or after the operation' three developed during the operation, and one required reoperation for postoperative thrombosis. No flaps were lost. Three patients developed deep venous thrombosis (DVT) or pulmonary embolism (PE) postoperatively; the two patients with DVT were later found to be resistant to activated protein C. The patient with a PE had developed multiple metastases by one year postoperatively. We compared the six patients who developed anastomotic and systemic thromboembolic events with those whose operations were uncomplicated and no significant differences were found either in their characteristics or overall events during operation.     

Successful Liver-Kidney Transplantation in Two Children With aHUS Caused by a Mutation in Complement Factor H

A 12-month-old boy and his 16-year-old aunt became acutely ill 6 months apart and were diagnosed to have atypical hemolytic uremic syndrome (aHUS). Genetic analysis revealed heterozygous R1215Q mutation in complement factor H (CFH) in both patients. The same mutation was found in five healthy adult relatives indicating incomplete penetrance of the disease. The patients developed terminal renal failure and experienced reversible neurological symptoms in spite of plasma exchange (PE) therapy. In both cases, liver-kidney transplantation was successfully performed 6 months after the onset of the disease. To minimize complement activation and prevent thrombotic microangiopathy or overt thrombotic events due to the malfunctioning CFH, extensive PE with fresh frozen plasma was performed pre- and perioperatively and anticoagulation was started a few hours after the operation. No circulatory complications appeared and all four grafts started to function immediately. Also, no recurrence or other major clinical setbacks have appeared during the postoperative follow-up (15 and 9 months) and the grafts show excellent function. While more experience is needed, it seems that liver-kidney transplantation combined with pre- and perioperative PE is a rational option in the management of patients with aHUS caused by CFH mutation.     

Zinc chloride smoke inhalation: a rare cause of severe acute respiratory distress syndrome

Zinc chloride smoke inhalation is a rare cause of slowly progressive and often fatal acute respiratory distress syndrome (ARDS). The conventional treatment includes intravenous N-acetylcysteine, L-3, 4-dehydroproline, methylene blue, and respiratory support according to the lung protective strategy. This report presents the cases of three patients with serious zinc chloride inhalation and ARDS, the last of whom survived after prolonged intensive care, videothoracoscopic excision of emphysema bullae, and recurrent chemical pleurodesis. Received: 3 March 1999 Final revision received: 6 July 1999 Accepted: 27 October 1999     

Reliability and validity of the Finnish version of the Lower Extremity Functional Scale (LEFS)

Purpose: The present study aimed to assess the psychometric properties of the Finnish version of the Lower Extremity Functional Scale (LEFS) among foot and ankle patients.

Methods: The LEFS was translated and cross-culturally adapted to Finnish. We assessed the test–retest reliability, internal consistency, floor-ceiling effect, construct validity and criterion validity in patients who underwent surgery due to musculoskeletal pathology of the foot and ankle (N?=?166).

Results: The test–retest reliability was high (ICC = 0.93, 95% CI: 0.91–0.95). The standard error of measurement was 4.1 points. The Finnish LEFS showed high internal consistency (Cronbach’s α?=?0.96). A slight ceiling effect occurred as 17% achieved the maximum score. The LEFS correlation was strong with the 15D Mobility dimension (r?=?0.74) and overall HRQoL (r?=?0.66), pain during foot and ankle activity (r=??0.69) and stiffness (r=??0.62). LEFS correlated moderately with foot and ankle pain at rest (r=??0.50) and with physical activity (r?=?0.46).

Conclusions: The Finnish version of the LEFS showed reliability and validity comparable to those of the original version. This study indicates that the Finnish version of the LEFS serves both clinical and scientific purposes in assessing lower-limb function.

• Implications for Rehabilitation

• The Finnish version of the Lower Extremity Functional Scale (LEFS) is a reliable and valid tool for assessing lower-extremity musculoskeletal disability in Finnish-speaking population.

• Investigation of the psychometric properties of the Finnish version of the LEFS showed validity and reliability comparable to those of the original English version.

• The Finnish LEFS is easy to complete and suitable for clinical, rehabilitation and research purposes.

     

Unusually young Merkel cell carcinoma patients are Merkel cell polyomavirus positive and frequently immunocompromised

Merkel cell carcinoma (MCC) is a rare neuroendocrine carcinoma typically affecting the elderly. Only 5% to 10% of the patients are younger than 50 years at the time of the diagnosis. The purpose of this study was to compare the tumour and disease characteristics between exceptionally young and the typical elderly MCC population. Further, quantitative polymerase chain reaction analysis was used to study for Merkel cell polyomavirus (MCPyV) in their primary MCC tumours. Patients diagnosed with MCC in Finland from 1979 to 2004 were identified from the files of the Finnish Cancer Registry. Presence of MCPyV DNA in tumour samples was investigated using quantitative polymerase chain reaction. Six of 181 MCC patients were ≤50 years, with male-to-female ratio of 1:1. An altered immune condition state was observed in five patients. The Kaplan–Meier analysis showed a trend towards worse MCC-specific survival both in 5- and 10-year surveillance for younger patients. Five primary tumour tissue samples, available for analysis, contained MCPyV DNA. Our data shows that MCC, ≤50 years of age, is rarer then previously estimated. Moreover, our data showed marked differences both in patient demographics and in primary tumour characteristics as compared to surveys including older MCC patients. Course of disease seemed to be worse in the exceptionally young patients. All MCC primary tumours in this study contained MCPyV DNA.     

Reproducibility of measurements of exhaled NO, and cell count and cytokine concentrations in induced sputum.

Sputum induction is a noninvasive, well-tolerated method for studying airway inflammation. When induction with hypertonic saline is repeated at short time-intervals (<24 h), the cell profile of sputum has not been reproducible. To determine the proper interval between sampling cell profiles and cytokine contents of sputum samples that had been induced 48 h apart, were compared. In addition, the inducible nitric oxide synthase (iNOS) expression of sputum cells was compared to the levels of exhaled nitric oxide (NO). Sputum induction and measurement of exhaled NO was performed in 31 healthy nonatopic volunteers. Cell differentials were counted. Concentrations of interleukin (IL)-4, IL-6, tumour necrosis factor (TNF)alpha, eosinophil cationic protein (ECP) were measured in sputum supernatant, and iNOS was determined. Reproducibility of cell counts was high (r=0.836 total cells, r=0.762 neutrophils, r=0.966 eosinophils, r=0.742 macrophages). IL-4 (r=0.398), IL-6 (r=0.566), TNFalpha (r=0.658) and ECP (r=0.501) were also less reproducible in healthy volunteers. Consistent with the low levels of NO in the exhaled air (18.5+/-2.6 ppb and 19.3+/-2.8 parts per billion (ppb) on the two study days, r=0.976, p=0.0000), expression of iNOS was not detected. In conclusion, in healthy subjects, induced sputum cell counts are reproducible. Even though the success rate in nonatopic populations is relatively low, sputum induction appears to be a valid method for detecting inflammatory changes within the airways, when being performed 48 h apart.     

Thirty-year cumulative incidence of chronic bronchitis and COPD in relation to 30-year pulmonary function and 40-year mortality: a follow-up in middle-aged rural men

PURPOSE: To describe the 30-year cumulative incidence of chronic bronchitis and COPD in relation to smoking habits. The effect of chronic bronchitis on pulmonary function and mortality was also examined. METHODS: Middle-aged men belonging to two rural Finnish cohorts of the Seven Countries Study (n = 1,711 in 1959) were followed up for up to 40 years until 2000. Standard questionnaires were used to measure chronic bronchitis, and repeated spirometry was used to evaluate pulmonary function during the 30 years. Forty-year mortality data were examined. RESULTS: The cumulative incidence of chronic bronchitis and COPD was 42% and 32%, respectively, in continuous smokers, compared to 26% and 14% in ex-smokers and 22% and 12% in never-smokers. During the follow-up, subjects with chronic bronchitis had on average 252 mL (95% confidence interval, 211 to 293 mL) lower forced expiratory volume than those without it. The decrease in forced expiratory volume attributable to chronic bronchitis was most pronounced in those with persistent symptoms and in smokers. In subjects with chronic bronchitis, all-cause mortality was increased by a hazard ratio of 1.30 (95% confidence interval, 1.02 to 1.65). Smokers with chronic bronchitis who decreased their daily cigarette consumption increased their median life span by 2.4 years. CONCLUSIONS: The lifetime risk of chronic bronchitis among smokers is approximately two in five, and almost one half of smokers who have chronic bronchitis also acquire COPD. Chronic bronchitis is related to earlier death, also in never-smokers, probably partly through a rapid decline in pulmonary function.     

Comparison of inhaled salbutamol powder and aerosol in asthmatic patients with low peak expiratory flow level

Summary The short-term bronchodilator effects of dry salbutamol powder and a pressurized salbutamol aerosol were compared in 22 patients with severe asthma, on 3 consecutive mornings, in a double-dummy cross-over study. Only patients with peak expiratory flow (PEF) rate lower than 250 l/min, were recruited. PEF measurement was employed to assess changes in ventilatory function induced by inhalation of the drugs. No significant difference was found between the PEF changes induced by the dry salbutamol powder (400 µg) and the pressurized aerosol (200 µg). Both forms of the drug produced a significant rise in mean PEF values. The study shows that even in asthmatic patients with poor ventilation, a dry powder inhaler and pressurized aerosol are effective means of drug delivery to the lungs.     

Inflammatory mediators in nasal lavage, induced sputum and serum of employees with rheumatic and respiratory disorders.

Exposure to microbes present in mould-damaged buildings has been linked to increased frequency of various inflammatory diseases. The current study examined differences in inflammatory mediators in nasal lavage (NAL), induced sputum (IS) and serum of occupants with rheumatic or respiratory disorders and their controls, all working in the same moisture-damaged building. Exhaled nitric oxide (NO) measurements, lung function tests, skin-prick tests and health data collection by questionnaire were performed. Concentrations of NO, interleukin (IL)-1, IL-4, IL-6 and tumour necrosis factor-alpha in NAL, IS and serum (excluding NO and IL-1) of the subjects were measured during an occupational exposure period and the vacation period without such exposure. The concentrations of IL-4 in NAL fluid were significantly higher among all occupants during the working period (geometric mean 8.5 microg x mL(-1), range 0-206.5 microg x mL(-1)), as compared to that during vacation (0.4 microng x mL(-1) range 0-3.7 pg x mL(-1)) (p = 0.008). Absence from the work environment also significantly diminished reporting of symptoms. IL-4 levels in the serum of case subjects were significantly higher than in controls. Moreover, employees with respiratory symptoms had markedly higher exhaled NO values than their controls (p = 0.028). In summary, these data suggest that mediators in nasal lavage samples reflect the occupational exposure to moulds, whereas possible indicators of existing disorders are detectable in serum.