Biomedical subjects
Publications and source records attributed to H H de Boer.
The presence of antibodies against human leukocyte antigens (HLA) in recipients of cryopreserved, non-tissue-antigen-matched human meniscal allografts was evaluated. Serological HLA typing was performed for both class I and class II antigens. The results showed that 11 of 18 recipients became sensitized.
We reviewed the treatment and results of 22 Bennett's fractures. Of these fractures, treated by closed reduction and plaster immobilization, 20 were available for follow-up. Eighteen patients had a subjectively satisfactory outcome, and seven had a radiographically confirmed arthrosis of the first carpometacarpal joint. Of these, two were severe and painfully impaired. Nonanatomic reduction was seen in six of the seven patients with arthrosis and is thus considered a prognostic factor of posttraumatic arthrosis.
In a prospective study, we evaluated the clinical results of 23 patients with a cryopreserved non-tissue-antigen-matched meniscal transplant at a follow-up of from two to five years. These early results were satisfactory in 20 patients. Three transplantations failed and the allografts were removed after 12, 20 and 24 months. Post-transplantation arthroscopy showed that most meniscal transplants had healed to the knee capsule. Histological examination showed revascularisation of the transplant and evidence of viable meniscal chondrocytes. The failures were probably caused by malalignment, resulting in impaired revascularisation of the graft.
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Treatment of patients with an established disabling compartment arthrosis after total meniscectomy is an important clinical problem. Meniscal transplantation may be an alternative method of treatment. Between 1989 and 1992, 25 cryopreserved nontissue antigen matched meniscal transplantations were performed. In three patients with a medial meniscus, the transplantation failed because of partial loosening of the meniscus. The donor meniscus was removed in one case after 12 months and in the other two cases after 20 and 24 months. In two cases, there was a varus malalignment of the knee. In the third case, the knee was unstable because of an insufficient anterior and posterior cruciate ligament. The retrieved menisci were stained with enzyme and immunohistochemical reactions. Focal areas of degeneration were noted, with vital cells around the microvascular supply and at the synovial side. The growth potential of vital parts of the grafts, as shown by proliferation markers, seemed to be virtually nil. The success of meniscal transplantation seems to depend on factors responsible for vascularization. Malalignment and instability of the joint, causing abnormal pressure on the graft, may be responsible for vascular damage leading to degeneration and loosening of the graft.
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The short term results of 15 cryopreserved non-tissue-antigen matched meniscus transplantations are described. The clinical outcome is satisfactory. Histological and histochemical studies showed that meniscuschondrocytes can survive cryopreservation and transplantation.
OBJECTIVE: To identify the contribution of necropsy results to the audit care of severely injured patients. DESIGN: Retrospective study. SETTING: University Hospital in The Netherlands. SUBJECTS: 56 patients who died of severe trauma or its complications during the 10 year period, 1977 to 1987. MAIN OUTCOME MEASURES: Correlation between clinical and necropsy findings. RESULTS: The clinical and necropsy findings corresponded in 31 patients (55%). The necropsy brought to light errors in diagnosis or treatment that might have affected survival in eight cases (14%). The most common missed diagnoses were bronchopneumonia and severe haemorrhage, and the most common cause of death was sepsis. Age, length of stay in hospital, and time between admission and operation were not correlated with accuracy of diagnosis or adequacy of treatment. CONCLUSION: Necropsies in patients who die after severe injuries make a useful contribution to the audit of the care of patients admitted with such injuries.
An autopsy study was performed to quantify diagnostic fallibility in clinical surgery. Autopsy results in 312 surgical patients were compared with clinical findings. The primary clinical diagnosis was correct in 93 per cent of patients; complications had been correctly diagnosed in 60 per cent and error in treatment was found in 16 per cent. Error in treatment had an adverse impact on the course of disease in 11 per cent of patients. Infective complications such as abdominal sepsis and bronchopneumonia were encountered most often. Sensitivity was low for the clinical diagnosis of pulmonary embolism, bronchopneumonia, myocardial infarction and terminal haemorrhage. Statistical analysis showed that sudden unexpected death is the most obvious condition in which a high yield is expected from a post-mortem examination. Autopsy remains a valuable means of quality control in clinical surgery and could be a basis for surgical audit.
Collagen degradation is thought to be an integral part of the healing sequence of intestinal anastomoses, but almost nothing is known about the enzyme activities involved. We have studied collagenolytic activities, extracted from 1 day-old intestinal anastomoses in the rat. Using either soluble type I collagen or fibrillar type I or type III collagen as a substrate, activities measured in extracts from anastomotic segments were compared to those in extracts from uninjured intestine, removed at operation: in all cases, the collagenolytic activity in anastomotic extracts was significantly higher. This increase was significantly more pronounced in large bowel than in small bowel. The activities were strongly inhibited by serum and metallo-chelating compounds. Analysis, by means of SDS-polyacrylamide gel electrophoresis, of the reaction products of the degradation of fibrillar type I collagen by the extracts revealed the presence of a multitude of fragments, amongst them TcA fragments characteristic for the activity of mammalian collagenase. Thus, the degradative capacity towards various collagen substrates is enhanced in the anastomotic area during the first postoperative period and a true mammalian collagenase is one of the enzymes present.
Antineoplastic agents affect the healing of intestinal anastomoses. They often induce anorexia and diarrhea, possibly caused by morphological changes in the small intestinal mucosa. These changes were evaluated in the rat ileum. Animals in group I underwent only intestinal surgery while those in groups II and III underwent surgery on the third day of a 5-day course with cisplatin (in two different doses), bleomycin, and 5-fluorouracil. The parameters were: number of mitoses in crypts, crypt depth, villus height, width, and contour length, measured in the mucosa of primarily resected segments of the ileum and of the anastomotic area. Surgery yields an increased crypt depth and villus length in the anastomotic area without changing villus width. The changes in intestinal crypts precede those in villi. Antineoplastic drugs decrease crypt mitotic rate, villus height, width, and contour length. After cessation of antineoplastic chemotherapy mitotic activity increases. The shallower and shorter villi increase in width and length resulting in an increased villus contour length and area. A linear relation exists between villus contour length and villus height and width. Thus, antineoplastic polychemotherapy, dose-dependently, reduces and surgical trauma increases intestinal proliferative activity. However, the morphologic changes do not unequivocally explain possible metabolic disturbances causing retarded intestinal wound healing.
An analysis of autopsy findings in 68 patients who died with vascular surgical disorders was performed. Incorrect diagnoses and therapy were evaluated. It was found that complications of the primary disease or its treatment were frequently missed clinically (41%). Septic complications and severe hemorrhage were common in examinations of morbidity and mortality. In 13% of cases a treatment error with adverse impact on survival was detected. It is concluded that postmortem examination is a valuable tool in the final evaluation of patient care in a vascular surgical unit. A repeated plea for the autopsy is supported by this study.
The effects of parenteral nutrition on the healing of experimental ileal and colonic anastomoses constructed on the 3rd day of a 5-day cytostatics course were investigated. Intravenous saline alone already reduced weight loss induced by cytostatics while parenteral nutrition almost completely prevented postoperative loss of weight. A negative effect of cytostatics on anastomotic bursting strength was found in the ileum 7 days after operation. Parenteral feeding negated this effect but had no positive effect on anastomotic hydroxyproline content. Thus, parenteral nutrition increases the strength of intestinal anastomoses, constructed during a cytostatics regimen, but intravenous saline alone also appears to have a similar effect.
Five scoring systems for predicting the severity and outcome of acute haemorrhagic necrotizing pancreatitis were retrospectively evaluated in 39 patients. The respective scores were Ranson, Imrie, APACHE II, multiple organ failure (MOF) and Sepsis Sensitivity Score (SSS). Twenty-two (56%) of the patients died. The survivors were significantly younger than the non-survivors, 68% of whom died within 3 weeks of admission to the intensive care unit. Stay in the unit was significantly longer in the former group. Sensitivity in prediction of death was best with APACHE II score greater than 9 (96%) and Ranson score greater than or equal to 3 (95%). Of the five scores, MOF greater than or equal to 4 gave the best equilibration between sensitivity (73%) and specificity (76%) and the strongest prediction of lethal outcome (80%). Although the independent factor age had low sensitivity (55%), it showed the highest values for specificity (88%) and prediction of death (86%). APACHE II scoring is concluded to be best for grading the severity of disease on admission to intensive care, while the MOF score is best for monitoring the degree of organ dysfunction and the intensity of supportive treatment.
Histologic evaluation of intestinal wound healing with and without cytostatics was performed in 36 rats. Variables were the relative position of the wound edges in mucosa and muscularis, necrosis, exudate, granulation tissue, granulocytes, macrophages, fibroblasts, restoration of the mucosal epithelium, and repair of the muscularis propria. The relative position of the wound edges in the mucosa and the muscularis in the initial phase of wound healing depended on technique but appeared to improve in the later phases of wound healing. It was not affected by the administration of antineoplastic agents; neither were muscularis repair, epithelial restoration of the mucosa, necrosis, nor exudate. Granulation tissue, fibroblasts and macrophages were present in maximal amounts after 7 days appearing later or showing this maximum at a different moment in time when antineoplastic agents were given. The processes of epithelial and muscularis repair were not influenced by the relative position of the wound edges. Granulation tissue, macrophages, and fibroblasts were the best parameters for measuring the histologic evolution of intestinal wound healing, and the effects of antineoplastic agents upon it.
The results of autopsy of 77 patients who died because of surgical disease of the digestive tract were compared with antemortem findings. An analysis was performed to identify missed diagnoses and incorrect therapy. Primary diagnoses had not been frequently missed, but many complications of the primary disorder or treatment had been overlooked. Many patients died because of septic conditions. Error in treatment, with an adverse impact on the course of the disease as assessed by the postmortem examination, occurred in 9 percent of the patients. The most common error had been failure to reoperate upon patients with an intra-abdominal complication. Unexpected death was significantly associated with incorrect diagnosis; failed or inadequate diagnostic methods were significantly associated with treatment failure (chi-square tests). The autopsy remains a valuable procedure in clinical operation. Selection of patients for autopsy, as indicated by decreasing autopsy rates, is not justified.
The reconstruction of large skeletal defects presents a challenging problem to the orthopaedic community. Currently bone graft surgery enjoys renewed interest because of the increased demand for bone grafts in limb salvaging bone tumour surgery and reconstructive surgery on failed arthroplasties. Two patients treated with an allograft are presented.
Although steroids are generally thought to impair intestinal anastomotic healing, this effect has never been proven unequivocally in either clinical or experimental studies. We have investigated the influence of methylprednisolone (2.5 or 10.0 mg kg-1 day-1) given from 2 days before operation onwards, on 3-day-old and 7-day-old ileal and colonic anastomoses in rats. Anastomotic abscesses occurred more frequently in the ileum, but not in the colon, after steroid medication. However, methylprednisolone did not lower anastomotic bursting pressures in either of the bowel segments. Comparison of the hydroxyproline content of the anastomotic segment yielded no significant difference between control and methylprednisolone groups in either small or large bowel. Thus, healing of experimental colonic anastomoses remains unaffected by short-term administration of this corticosteroid.