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Pericardial tamponade is a feared, though rare complication during myocardial infarction. We present a case of an unusual hemorrhagic appearance of pericardial fluid accumulation during ibuprofen overdose and myocardial infarction.

Objective: Improvement in survival and quality of life are the primary indications for coronary artery bypass graft (CABG) operations. Among elderly patients the main goal of surgery is not necessarily to prolong life, but to improve the health-related quality of life. Factors associated with mortality and morbidity following CABG surgery have been well defined, but the quality of life and functional capacity in elderly patients undergoing CABG are poorly documented. The aim here was to investigate changes in health-related quality of life, overall performance status and symptomatic status during 1 year after CABG surgery., Methods: Comprehensive data on 508 CABG patients were prospectively collected, including preoperative risk factors and postoperative morbidity in a surgical center and in all eighteen secondary referral hospitals up to discharge. The RAND-36 Health Survey (RAND-36) was used as indicator of quality of life. The primary outcome was change in the physical component summary, mental component summary and General Health summary scores from the RAND-36. Karnofsky dependency category was used to assess overall performance status, and symptomatic status was estimated according to New York Heart Association (NYHA) class. All assessments were made preoperatively and repeated 12 months later. Analysis was based on three age groups: 64 years or less (282 patients), 65-74 years (175 patients), and 75 or more years (51 patients)., Results: Thirty-day and 1-year survival rates were 98.2 and 96.7%, respectively. A great majority (86.4%) of the patients recovered without major complication. In all, the present data showed significant improvement in all eight domains of QOL as well as in functional capacity and NYHA class during the 1st year after CABG. However, the mean change in RAND-36 Mental Component Summary scores among patients aged 75 years or more did not reach a statistically significant level (P=0.097) and they had significantly minor improvement as compared to younger patients (P<0.05). Moreover, their General Health score improvement was poorer and statistically insignificant (P=0.817)., Conclusions: Elderly patients not only have higher mortality and morbidity but also derive less benefit from CABG regarding certain aspects of QOL.

Aim: This clinical report details a comparison between the conventional on-pump and beating heart off-pump techniques with particular attention to patient characteristics, perioperative variables and early outcomes., Methods: We collected prospectively a comprehensive data body from 1131 consecutive patients who underwent isolated CABG in Tampere University Hospital. The morbidity, mortality and length of stay data from the secondary referral hospitals were also collected. One thousand and sixteen (89.8%) patients underwent bypass grafting with cardiopulmonary bypass (CPB, on-pump) and 115 (10.2%) patients without the CPB (off-pump)., Results: Thirty-day mortality rates were 4.0% (on-pump) and 2.6% (off-pump, p=0.5). The total postoperative length of stay was 12 (on-pump) and 10 (off-pump) days as the medians (p<0.001). Adverse outcome events among the on-pump and off-pump patients were as follows: postoperative stroke, 2.5% and 0.9% (p=0.3); perioperative myocardial infarction, 7.0% and 7.8% (p=0.7); impaired renal function, 9.5% and 4.3% (p=0.3); re-sternotomy for bleeding or low output, 5.3% and 4.3% (p=0.2); new-onset atrial fibrillation, 38.9% and 24.6% (p=0.002) and the need for red cell transfusions in ICU, 50.3% and 22.6% (p<0.001). Eighty-three percent of the on-pump and 85.2% of the off-pump patients (p=0.5) had a favorable outcome without a major complication., Conclusion: Considering the limitations with a nonrandomized study design, we conclude that off-pump CABG is a safe and comparable method of myocardial revascularization in terms of early outcomes. Overall length of stay shorter by 2 days, over a third shorter ventilation time, fewer red cell transfusions and lower frequency of postoperative atrial fibrillation favor off-pump surgery.

Objectives: The aim of the present study was to evaluate the performance of three different preoperative risk models in the prediction of postoperative morbidity and mortality in coronary artery bypass (CAB) surgery., Methods: Data on 1132 consecutive CAB patients were prospectively collected, including preoperative risk factors and postoperative morbidity and in-hospital mortality. The preoperative risk models CABDEAL, EuroSCORE and Cleveland model were used to predict morbidity and mortality. A C statistic (receiver operating characteristic (ROC) curve) was used to test the discrimination of these models., Results: The area under the ROC curve for morbidity was 0.772 for the CABDEAL, 0.694 for the EuroSCORE and 0.686 for the Cleveland model. Major morbidity due to postoperative complications occurred in 268 patients (23.6%). The mortality rate was 3.4% (n=38 patients). The ROC curve areas for prediction of mortality were 0.711 for the CABDEAL, 0.826 for the EuroSCORE and 0.858 for the Cleveland model., Conclusions: The CABDEAL model was initially developed for the prediction of major morbidity. Thus, it is not surprising that this model evinced the highest predictive value for increased morbidity in this database. Both the Cleveland and the EuroSCORE models were better predictive of mortality. These results have implications for the selection of risk indices for different purposes. The simple additive CABDEAL model can be used as a hand-held model for preoperative estimation of patients' risk of postoperative morbidity, while the EuroSCORE and Cleveland models are to be preferred for the prediction of mortality in a large patient sample.

Paraoxonase (PON) is an antioxidative enzyme, which eliminates lipid peroxides. PON has two common polymorphisms (M/L55 and R/Q192) that influence PON concentration and activity. We studied whether the M/L55 or R/Q192 genotype relates with the severity of atherosclerosis of the abdominal aorta, and the mesenteric and common iliac arteries in 123 consecutive autopsy cases (90 males and 33 females, aged 18-93 years). The severity of atherosclerosis in the arteries was evaluated, and the percentage of stenosis was measured. The intimal thickness in the internal elastic lamina (IEL) of the coeliac (CA), superior mesenteric (SMA) and inferior mesenteric (IMA) arteries were measured by light-microscopy. The LL homozygous men had more atherosclerotic plaques and complicated lesions in the common iliac arteries (56.8%) than the M allele carriers (28.3%, P=0.007). In logistic regression analysis, age (P<0.001) and the PON M/L55 genotype (P=0.015) were associated significantly with the severity of atherosclerosis in the common iliac arteries independent of smoking status, R/Q192 genotype, hypertension, diabetes mellitus, BMI and sex. The mean intima of the IMA was significantly thicker (P=0.035) and the number of stenotic lesions in SMAs significantly higher (P=0.008) in the LL homozygous men than M allele carriers. In turn, the R/Q192 genotype was not statistically significantly associated with plaque type, intimal thickness in the IEL or with the number of stenotic lesions. This study demonstrates that PON L55 homozygosity is an independent risk factor for autopsy-verified atherosclerosis in Finns.

Objective: To evaluate long-term consequences of genetic carrier testing performed in childhood in terms of awareness and comprehension of the test result, and the social and psychological significance of such testing., Study Design: The families of 66 young females who had been tested for carriership during childhood between 1984 and 1988 were approached. Of the 66 families, 23 young females in families affected by Duchenne muscular dystrophy (DMD), 23 young females in families affected by hemophilia A (HA), and their mothers participated in our study. We used a questionnaire including multiple-choice and open-ended questions., Results: Of the young female participants tested in the families affected by DMD or HA, 65% knew their test results. Only 65% of DMD mothers and 78% of HA mothers remembered correctly the test results of their daughters. The majority (83%) of the young females tested sought no genetic counseling when reaching adulthood. The reason for this was not determined. Most (78%) reported that the test result had not influenced their lives, whereas some felt relieved to know they had not been carriers. Talking about hereditary disease in the family and between friends was open, and results of the carrier test had usually been told to friends., Conclusion: Carrier testing was in most cases correctly understood and the matter openly discussed. Our results do not suggest that testing in childhood had caused serious harm to the young individuals tested. On the other hand, we found no obvious benefits from this early testing.

The defects in the internal elastic lamina (IEL) have been proposed to be important for the migration of smooth muscle cells into the intima during atherosclerosis. We investigated the association of a genetic factor--apolipoprotein E (apoE) genotype--with the number of gaps in the IEL of the artery wall in 123 consecutive autopsy cases (90 male, 33 female) aged 18-93. At autopsy, the circumference of the IEL and the number of gaps in the IEL were measured in circular samples of the coeliac; (CA), superior mesenteric (SMA) and inferior mesenteric (IMA) arteries. In the series, the number of gaps per millimetre in the IEL of CA, SMA and IMA were associated with intimal thickening (P<0.0001, P=0.01 and P=0.005, respectively). In men, apoE genotype was significantly associated with the number of gaps in the IEL of the CA and IMA (P=0.033 and P=0.041, respectively). The carriers of epsilon4/3 or epsilon4/4 genotype had higher number of gaps in CA than the carriers of epsilon3/3 genotype (2.30+/-2.63 vs. 1.38+/-1.83 gaps/mm, P=0.035) and also higher number of gaps in IMA than the carriers of epsilon3/2 (2.18+/-1.71 vs. 0.66+/-0.60 gaps/mm, P=0.041). The results suggest that the apoE varepsilon4 allele may be involved with IEL fragmentation in men. This may be mediated through higher serum cholesterol associated with the varepsilon4 allele.

The vascular anastomoses are usually made with sutures. Some mainly experimental studies have been published about a new method of doing the vascular anastomoses with metal clips. We studied the suitability of vascular closure staple (VCS) clip applier system for making the anastomoses in femoropopliteal and femorotibial arterial reconstruction. During an 11-month period, VCS clips were used in 17 out of 27 patients who were operated due to severe claudication or incipient gangrena of the foot. Altogether 26 anastomoses were made with VCS clips using either great saphenous vein or PTFE graft. The making of anastomosis was easy and reliable. No postoperative bleeding was noticed. All anastomoses were patent 4-6 weeks postoperatively studied by palpation and measured by ankle brachial pressure index (mean 0.96). In Duplex Doppler examination all studied patients had well patent anastomoses on an average 11 months after the operation. With VCS clip applier system, it is possible to do anastomoses in arteriosclerotic arteries like in femoropopliteal reconstructions. This method helps making reliable anastomoses more easily.

The present nationwide, multicenter clinical study was carried out in 26 departments of surgery to define the incidence and attendant mortality of intestinal infarction following abdominal aortic surgery, and to identify patients at risk of it. The data consist of 1752 patients who underwent abdominal aortic reconstruction during 1991-1993 as recorded in the Finnish national vascular registry (FINNVASC). Among the 1752 operations, 27 patients treated at 14 different hospitals had intestinal ischemia, and the complete patient records of all 27 cases were reanalyzed. The incidence of bowel infarction was 1.2%. Among patients operated on for a ruptured aneurysm it was 3.1%, whereas 1.0% of patients with nonruptured aneurysm and 0.6% of those operated on for aortoiliac occlusive disease developed intestinal infarction. In 14 patients (67%) the lesion affected the left colon. The overall 30-day mortality rate was 13% but reached 67% among those with intestinal infarction. We conclude that acute intestinal ischemia with bowel infarction is an infrequent but serious complication of abdominal aortic surgery. It is mainly related to surgery due to aneurysmal disease, and patients with occlusive aortoiliac disease present ischemic complications in the intestines less often. Hypotensive patients being treated for ruptured aneurysm are at greatest risk of intestinal ischemia.

Carrier testing of children for inherited disease that will not affect the health of the children themselves but of their future children is generally regarded as problematic. In this retrospective study, we determined how young women had experienced genetic carrier testing when they were children. The families of 66 young females who had been tested for carriership during childhood between 1984 and 1988, were approached. Of them, 23 young females in families affected by Duchenne muscular dystrophy, and 23 young females in families affected by hemophilia A, and their mothers, participated in our study. We used a questionnaire including multiple-choice and open-ended questions. We recorded general attitudes to testing, satisfaction with testing, degree of trust in test results, making decisions regarding testing, privacy, and opinions about age at testing. Thirty-five out of 46 of the young women tested (76%) were satisfied with carrier testing in childhood. However, the young women in whom the test results had been uncertain were statistically more often unsatisfied with the testing than those who had been found or not found to be carriers (p = 0.002). In each group, the opinions of mothers were parallel to those of their daughters. Seventy-eight percent of daughters regarded carrier testing as a family matter in which parents can make a decision. About half of those tested recalled that they had been allowed to participate in decision-making in a satisfying way. Thirty-nine out of 46 (85%) of the young women tested, and 33/46 (72%) of the mothers, suggested that carrier testing should be performed in childhood or during teenage years.

To evaluate the intimal thickness and continuity of the internal elastic lamina (IEL) in the mesenteric arteries, proximal segments of the coeliac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) were studied light microscopically in 123 consecutive postmortem examinations. The mean age of the subjects was 62 years. Arterial segments were fixed in formalin, embedded in paraffin blocks, sectioned, and stained with Masson's trichrome. Fifty-one per cent of the samples examined showed at least minimal intimal thickening. The occurrence of significant luminal narrowing increased with age. We found a positive correlation between defects in the IEL and thickness of the intima in the mesenteric arteries, which is in harmony with previous observations showing marked fragmentation of the IEL in atherogenesis.

A 7-year experience with 502 patients undergoing abdominal aortic reconstruction was reviewed to determine the incidence of intestinal ischemia and the clinical, anatomic and technical factors associated with this complication of aortic surgery. The other complications during the 30-day postoperative period were also collected. A total of 7 (1.4%) patients had intestinal infarction. Of these, colon necrosis occurred in 4, and 3 patients had necrosis in the superior mesenteric artery (SMA) territory. The occurrence of intestinal infarction after operation for ruptured aneurysm was 3.9% (4 patients) and for intact aneurysm 1.3% (3 patients), respectively. None of the 174 patients operated on for aortoiliac occlusive disease developed intestinal infarction. The development of colon necrosis after operation for ruptured aneurysm was mostly in relation to shock and diminished tissue perfusion. Suprarenal aortic clamping with subsequent SMA embolization, prolonged aortic clamping time, and a sporadic thrombosis of the SMA were responsible for small bowel necrosis. In 4 of 7 patients (57%) intestinal infarction led to death. An overall 30-day mortality was 18% (91 patients). Four per cent of these deaths were due to intestinal infarction.

Thrombosis in the visceral arteries is the most common cause of acute mesenteric ischemia. It typically occurs in areas of atherosclerotic narrowing. Atherosclerosis of splanchnic blood vessels also causes chronic mesenteric ischemia. In the present study, the occurrence of atherosclerosis in the celiac and mesenteric arteries was evaluated in an unselected Finnish autopsy series of 120 patients. Thirty-five patients (29%) had stenosis in the first few centimetres of mesenteric arteries. In 18 cases (15%) at least two mesenteric arteries were stenotic. The celiac artery was the most common site of mesenteric artery stenosis. More distally, only hemodynamically insignificant signs of macroscopic atherosclerosis, fatty streaks or fibrous plaques, observed. The occurrence of mesenteric artery stenosis was strongly associated with aging. Sixty-seven per cent of the subjects aged 80 or more presented with mesenteric artery stenosis, whereas the rate was 6% among those aged less than 40 years. Despite sometimes extensive stenotic alterations in the mesenteric arteries, only one patient in our study had bowel necrosis at autopsy. We conclude that atherosclerosis of mesenteric arteries commonly affects individuals of advanced age. As a part of general arteriosclerotic process of the circulatory system, mesenteric artery atherosclerosis is strongly associated with atherosclerosis in coronary arteries. In addition, there was an association between atherosclerosis in mesenteric arteries and cerebral arteries in the skull base. Thus, a characteristic triad of postprandial abdominal pain, food aversion, and weight loss in an elderly patient with other manifestations of arteriosclerosis should suggest a possibility of the visceral arterial insufficiency.

A migration-extinction model has been developed for the analysis of alary polymorphism and its adaptive significance in univoltine populations of water-striders (Gerris). It is assumed that all actual and potential population sites are identical with respect to all relevant variables, i.e. that populations do not live in a 'harlequin' environment. The model can be applied to other groups with alary polymorphism. The effects of isolation, environmental stability, and environmental productivity are discussed, with numerical examples. Isolation and stability enhance the optimality of short-wingedness, while temporariness of population sites selects for long-wingedness. Optima cannot always be realized. The models reveal several critical variables which are of interest in the ecological genetics of Gerris and which should be measured in natural populations: (a) extinction probabilities (a distinction being drawn between extinction due to drying up of the population site and extinction due to other causes), (b) extent of passive dispersal, and (c) the proportion of colonized population sites in a large geographical region.

Faunistic information shows that Denmark, Norway, Sweden and Finland were colonized by an average of 2.8 species (winners) and lost 0.6 species (losers) per decade and country in 1850-1970. The smallest passerines had best changes of colonization, but body size and colonization success were not related in nonpasserines; extinctions were fairly common among the largest species. Turnover was highest in a faunal group derived from steppe regions and in widely but often patchily distributed species. Population trends were generally similar over a larger region. Species turnover has changed the total number of breeding pairs only a little, but the colonization rate has been highest after 1950, when quantitative population changes have also been extensive.Extinction was most often caused by persecution and/or habitat changes by man (e.g. destruction of old forests). As large nonpasserines are often hunted or persecuted, they were frequent among the losers, many of which have specialized habitat requirements and usually migrate to the tropics.Over 50 of the 88 winners have been favoured by man's direct measures, such as introductions (3 spp.), relaxed persecution, or improved food conditions. Habitat changes (eutrophication, reduced grazing, and conifer plantations) stand out as major factors and may subtly interact with population parameters. Perturbation of tropical habitats in this century may have benefitted many Palearctic winter visitors: the frequency of tropical migrants among the winners has increased from 10% before 1900 to 38% after 1900. Population changes in central parts of the range probably led to several colonizations and extinctions at the periphery.In theoretical terms, r-selected species (small body size, large clutch size) were often winners, while K-species comprised the bulk of the losers, but this is no more than a general trend. Judged by their faunal origin, species adapted to effective dispersal were often winners, but also seemed vulnerable to environmental deterioration. Because many winners have invaded habitats that have been available for a long time, North European bird communities are probably often unsaturated.

European data from 15 long-term censuses of breeding land bird communities were analysed in order to measure community stability. Stability was here operationally defined as year-to-year persistence of community structure (total density, number of species, diversity, evenness of the species-abundance distribution, species list, and frequencies of species). Central Europe and southern Scandinavia formed a zone of fairly stable communities, but more northern communities were fairly unstable. This result contrasts with several recent arguments, but accords well with the classic dogma that instability of biological communities increases northwards in the northern hemisphere.Three theoretical explanations for the difference in stability between northern and southern communities were explored, and causal mechanisms underlying the hypotheses were specified and tested. Considerable evidence supported the hypothesis that environmental (climatic) unpredictability increases northwards and mainly causes the phenomenon observed. Gradients in productivity may, perhaps in interaction with unpredictability, also contribute to geographical differences in stability, but tests suggested that low diversity is not an important cause of northern instability.