| 51. |
- Larsson, Per-Göran
(författare)
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Bacterial vaginosis : Diagnosis, treatment and significance in gynaecological practice
- 1991
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Bacterial vaginosis (BV) is a syndrome which is characterized of a disagreeable vaginal discharge but not necessarily an increase in discharge and is present in nearly 20-30% of women attending gynaecological out-patient clinics. Some women have BV unknowingly but others suffer the disagreeable discharge as a lifelong nuisance and areconstantly visiting physicians without relief. This problem has even been regarded as an aesthetic problem and has received little attention, especially from gynaecologists. The diagnosis of BV is based on the fulfilment of three out of four clinical criteria as introduced by Amsel in 1983. Few studies have been carried out investigating whether BV is a risk factor for other gynaecological diseases such as bleeding disturbances or postoperative infections. The aim of this thesis was to investigate the role of BV in gyrtaecological diseases and to evaluate whether it is possible to make a reliable diagnosis of BV using saved smears, such as air-dried or Papanicolaou (PAP)-stained smears. This would make it possible to investigate a large material and enable retrospective investigations. Since vaginal leucocytosis has been regarded as a sign of genital infection, women with BY and leucocytosis have often been withdrawn from clinical studies. The presence of leucocytosis among women without BV was therefore also investigated to evaluate if this practice is justifiable. The diagnosis of BV using Amsel's criteria was compared with the detection of clue cells in air-dried vaginal smears or with the detection of clue cells in PAP-stained smears. Detection of clue cells in air-dried smears had a sensitivity of 96% and a specificity of 98% in diagnosing BY, and detection of clue cells in PAP-stained smears had a sensitivity of 90% and a specificity of 95%. Leucocytosis cannot be used to exelude BV as nearly 30 OJo of all women have leucocytosis regardless of whether BV is present or not and that healthy women can normally have transient leucocytosis during a menstrual cycle. The significance of BV in postoperative infections after gynaecological surgery and bleeding disorders was studied. BV was found to be a risk factor for pelvic inflammatory disease after first-trimester abortion, and postoperative infection following abdominal hysterectomy. A common complaint with a multifactorial etiology at a gynaecological out-patient department is bleeding disorder. Women with BV and with Mobiluncus were treated in a double-blind study with either metronidazole or with placebo. BV was successfully treated in 76% of the women. The bleeding disorder was regularized in all successfully treated women. Women with BV are at risk of developing a post-operative infection after first trimester abortion. One-hundred and seventy-four women with BV were treated in a doubleblind study with either metronidazole or placebo the week before the abortion. There were 12.2% post-operative infections in the placebo group compared to 3.6% in the group treated with metronidazole. The treatment thus reduced the incidence of infection by more than 3 times. Using simple clinical criteria it is possible to identify a risk group which if treated will reduce the incidence of postoperative infections after legal abortion. In Sweden with 36 000 abortions each year preoperative treatment of 10 000 women with BV will prevent 860 post-abortion PID's per year.
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| 52. |
- Leandersson, Per, 1958-
(författare)
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Mineral fibers, cigarette smoke, and oxidative DNA damage : An experimental study
- 1992
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This study concerns the ability of mineral fibers and cigarette smoke to generate reactive oxygen metabolites and to cause damage to DNA. The generation of hydroxyl radicals (OH") was demonstrated by using the DNA base, deoxyguanosine (dG) as a trapping agent for OH" and determining its hydroxylation to 8-hydroxydeoxyguanosine (80HdG), and oxidative DNA damage was assessed as formation of 80HdG in isolated DNA or in DNA of human lung cells in culture. Both asbestos (chrysotile) and manmade mineral fibers (~)were found to generate OH" and damage DNA in aqueous buffer solutions, andmore OH· was generated by the iron-containing rock and slag wools than by glass wool and ceramic fibers. The OH• generation by rock wool was decreased by treatment with heat, oxygen or desferrioxamine, indicating that chemical characteristics including iron on the fiber surface were important determinants of the OH" formation. A variety of natural mineral fibers (asbestos, erionite, and wollastonite) and MMMF (rock wool, glass wool, and ceramic fibers) were found to stimulate polymorphonuclear leukocytes (PMNL) togenerate OH" in the presence of exogenously added iron, and amosite, crocidolite, antophyllite, erionite, and wollastonite caused OH" formation also in the absence of exogenously added iron. Cigarette smoke potentiated the damaging action of rock wool onisolated DNA, suggesting that iron-containing fibers might catalyze O:H" formation from hydrogen peroxide generated in the smoke. Cigarette smoke-induced damage to isolated DNA was inhibited by tyrosinase and catalase, indicating that polyphenols in the smoke,e.g. hydroquinone and catechol, were important for the hydrogen peroxide generation. Cigarette smoke was also found to cause oxidative DNA damage and DNA strand break formation in cultured human lung cells by mechanisms involving OH" attack on the DNAmolecule and endonuclease activation. Moreover, cigarette tar was demonstrated to promote P:MNL-mediated DNA strand-break formation in human lung cells, and tar loaded with iron was more damaging than regular tar.These fmdings indicate that mineral fibers, by producing OH· themselves and by stimulating PMNL to generate OH· in the presence of iron, may cause oxidative DNA damage under experimental conditions. They also indicate that cigarette smoke may cause DNA base hydroxylation and DNA strand-break formation in human lung cells via mechanisms involving OH", and that iron is important for the OH•-formation. Altogether, the findings point to the possibility that mineral fibers may promote OH" generation by cigarette smoke and inflammatory cells and so increase the risk of DNA damage in human lung cells.
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| 53. |
- Ledin, Torbjörn, 1962-
(författare)
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Dynamic posturography in evaluating human equilibrium
- 1991
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Equilibrium assessment by means of posturography can be performed ina dynamic fashion, meaning that the environment does not remainstable during the test. In the EquiTest dynamic posturography version, the support surface and the visual surround are movable, actively or in response to body movements. Equilibrium ability is investigated in a sensory organ1zat1on (SO) part where six different combinations of vision (normal, sway referenced and absent) and support surface conditions (stable and sway referenced) are given. Postural responses to sudden translations and tiltings of the support surface are investigated in a movement coordination (MC) part. standardized dynamic posturography was utilized to assess equilibrium performance in different groups of subjects. In twentynine elderly healthy subjects, dynamic posturography evaluated the influence of age on equilibrium parameters. A decline compared to younger age groups was f~und. Fifteen of the elde:ly s~bjects underwent physical exerc~ses two hours a week dur~ng n~ne weeks, the remaining subjects served as controls. Significant improvement attributable to the exercises was found in one out of six so conditions and two out of twelve clinical equilibrium tests. In twenty-eight subjects with polyneuropathy, impaired equilibrium was found in so and delayed reactions to sudden support surface movements -w~re found in MC. Comparing dynamic posturography with neurological measures of polyneuropathy unveiled correlations between subjective clinical scoring and latencies to forward translations in MC and to equilibrium performance in three out of six so conditions. In seven subjects with chronic toxic encephalopathy due to industrial solvent exposure, impaired equilibrium was found in four out of six so conditions, although MC was normal. In thirteen healthy subjects, acute low level alcohol ingestion caused balance disturbances in SO conditions with abs7nt visual cues. In addition to disturbances of ocular smooth pursu1t and visual suppression of the vestibuloocular reflex in elevenabstinent chronic alcoholics, deteriorated equilibrium performance was found in four so tests out of six. Postural reactions to both sudden translations and tiltings of the support surface were found to be marred, in spite of normal nerve conduction velocities. The EquiTest dynamic posturography apparatus was cont:olle~ by amenu-driven interface constructed at the department, ~n wh~ch the user may expose the subject to arbitrary movement~ ~f the.supp~rt surface and the visual surround. The effects of v1s1on, d~rect~on and amplitude on postural reactions to su~den support surface translations were evaluated. Absence of v1sual cues caused more rapid correction maneuvres, but the translation direction did ~ot influence the reactions. Postural responses reflected translat1on amplitudes.
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| 54. |
- Lindberg, Eva
(författare)
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Crohn's disease : Studies on epidemiology, twins, aetiological factors and clinical course with special reference to smoking
- 1992
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In an epidemiological study of the incidence of Crohn's disease in Orebro county during the 25-year period 1963-1987, the mean annual incidence was 6.1/105 inhabitants. During the first five year period the mean incidence was 4.3 but during the following four quinquennia the incidence was stable at around 6.6/105 inhabitants. The point prevalence at 31/12 1987 was 146/105, with male to female ratio of 1:1.15. The mean age at diagnosis increased from 23 to 32 years. No cohort more prone to develop the disease was found. Of the 246 incidence cases 5 patients had died of Crohn's disease.The genetic influence was analysed in 18 monozygotic and 26 dizygotic twin palrs with Crohn's disease. Eight of the monozygotic palrs were concordant for the disease but only one of the dizygotic pairs. The proband concordance rate was 58.3% for monozygotic twins and the heritability of liability (r) 1.0. The corresponding figures for dizygotic twins were 3.9% and 0.47. When comparing with ulcerative colitis the heritability was found to be significantly stronger in Crohn's disease.A case-control study of smoking habits in 144 patients and 259 matched population controls showed that smoking doubled the risk of aquiring Crohn's disease. In former smokers a non-significant increased risk was observed.The effects of smoking on the localization and course of Crohn's disease was evaluated in 231 patients. Patients with high life time tobacco exposure (>150 cig.years) had small bowel disease more often than patients with low life time exposure. Heavy smokers(> 10 cig./day) had a slightly increased risk to be operated at least once, odds ratios after 5 and 10 years of follow up for heavy smokers compared to never smokersbeing 1.14 and 1.24 respectively. The risk for heavy smokers to be operated twice or more was even higher after 10 years offollow up, the odds ratio being 1.79. The accumulated number of fistulae and/or abscesses was higher in smokers than never smokers.Twenty-six monozygotic twin pairs with inflammatory bowel disease and 52 healthy controls were investigated for serum antibodies (IgA, IgG, IgM) against ovalbuntin, betalactoglobulin, gliadin, whole yeast (Saccharomyces cerevisiae) and mannan. Twins that had developed Crohn's disease displayed higher titers of all three antibodies towards mannan, and also higher IgA towards yeast. Their healthy twin hadhigher IgA to mannan and yeast. These results suggest that yeast cell wall material for instance mannan or some antigen rich in mannose and cross reacting with mannan might play an aetiological role in Crohn's disease.Conclusion: The incidence of Crohn's disease has been stable during the last 20 years. The genetic influence is important. Smoking increases the risk of aquiring Crohn's disease and heavy smokers have a worse outcome of the disease. Patients with high life time tobacco exposure more often have small bowel disease. Mannan or agents cross-reacting with mannan may play a role in the pathogenesis of the disease. However, not even similar smoking and dietary (as ntirrored by dietary antibodies) habits in identical twins are sufficient to cause disease. Additional factors are needed.
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| 55. |
- Lindgren, Richard
(författare)
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Climacteric Symptoms and Hormonal Treatment with special reference to Sequential Transdermal Therapy
- 1992
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Changes during female menopause include increased prevalence of vasomotor symptoms, vaginal symptoms, changes in sexlife and metabolic changes with increased risk of osteoporosis and cardiovascular disease. These changes are to some extent counteracted by estrogen replacement therapy.The aim was to study the prevalence of vasomotor symptoms, sexlife and estrogen replacement therapy in a postmenopausal population. The aim was also to study the effects of a new sequential transdermal estrogen/gestagen therapy on endometrium, bleeding pattern, Quality of Life and on plasma lipids and lipoproteins.Two epidemiological studies with postal questionnaires were answered by 1469 and 1867 women, respectively. Their ages were between 55 and 65 years. The prevalence of postmenopausal vasomotor symptoms was high. Eighteen percent of the women still had moderate to severe vasomotor symptoms even 15 years after menopause. There was a great discrepancy between the prevalence of vasomotor symptoms and hormonal replecement use. Many women discontinued treatment within the first year of treatment. The most common reason for discontinuation was lack of symptoms when treatment was ceased (25% ), followed by "fear of side-effects of the treatment" in 20% of the women.Most women had a regular sexlife even 15 years after menopause and the most common reason for sexual inactivity was lack of partner.One hundred and ten women with climacteric symptoms received a new sequential transdermal estradiol/norethisterone acetate therapy in a multi-centre study for one year. The therapy resulted in secretory endometrium in most women (65%) and only one woman developed hyperplasia after one year. The bleeding pattern for 1195 cycles were studied and 89% of the cycles -were regular or amenorrboic. The treatment resulted in improvement of Quality of Life after 9 months of treatment among 84% of the 110 studied women. The women experienced less anxiety and depression and increased vitality and self-control according to the Psychological Well Being Index. They also experienced better sleep according to the Sleeping Scale. The women also indicated less vasomotor and somatic symptoms and less anxiety and depression according to The Women Health Questionnaire. This test also showed improvements in sex-life, emotions and cognitive symptoms among the women.Twenty-five women at one centre were also studied concerning the effect of the treatment on plasma lipids and lipoproteins. The total cholesterol and LDL-cholesterol was reduced after three years of treatment. The triglycerides and HDL cholesterol was not significantly changed after 3 years of treatment.
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| 56. |
- Lindqvist, Kent, 1948-
(författare)
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Towards community-based injury prevention : the Motala model
- 1993
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In the Swedish County of Östergötland a comprehensive health policyprogramme including accidents was decided by the health authorities in 1988. An accident prevention programme (the "Motala Accident Prevention Study") had already started with an epidemiological analysis of accidents in the community. The Motala study is based on Bracht and Kingsbury's five-stage model of community development: community analysis, design and initiation, implementation, maintenance, and reassessment.The scientific reporting of the Motala study in this thesis is based on selected parts of the five-stage model and is grouped into reports from the community analysis (the main study) and an intervention study. The aim was to describe the panorama of accidents, their causes and effects in a defined community, and to account for the economic consequences of these accidents. A secondary aim was to provide an epidemiological basis for a sports accident prevention programme and out of that design such a programme, and to evaluate the effects of loan programmes on infant car restraints. In forthcoming papers other parts of the different stages of the model will be presented.Total population injury surveillance was performed in an area with apopulation of over 41,000. All accidents (N= 4,926) occurring within a 12-month period and requiring medical care were noted, giving a ratio of 118.9 per 1,000. They consisted of accidents in the home (35.0%), sports accidents (18.9%), accidents at work (13.7%), traffic accidents (12.8%), and "other" accidents (19.5%). Half of the victims covered by health insurance were put on sick leave in connection with the accident, and 12.6% of these were admitted to hospital. The age-group 13-19 years, and men between 20-29 years of age, showed the highest accident rate. The total cost to society for people in the labour force, including treatment cost and production loss, was 103.4 million SEK (15.7 million USD). The cost to society of uninsured people for time lost from "normal activities" because of an accident was estimated at 43.1 million SEK (6.5 million USD). There are three important conclusions with regard to the economic consequences of accidents. Firstly, it appears important to assess not only the productive working time of the injured people, but also other time, in which normal activities are restricted. Secondly, the findings reveal the conflict between the utilitarian and the dutybased ethical basis of health care activities. Thirdly, the results show the need for well-controlled studies with alternatives to show the effects of different actions.
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| 57. |
- Lindström, Torbjörn, 1952-
(författare)
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Insulin treatment of patients with type 2 diabetes : Risks and benefits
- 1993
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Patients with Type 2 diabetes and secondary failure to oral hypoglycaemic agents were characterized before and during insulin treatment. During oral treatment the 24-h area under the curve for free insulin in blood was similar to that in healthy subjects. However, the insulin profile was abnormal, with normal fasting free insulin but insufficient prandial response. Plasma concentrations of triglyceride-rich lipoproteins were elevated, and the high density lipoprotein (HDL) cholesterol concentration was low.Insulin treatment caused hyperinsulinaemia, with a 2-3-fold increase in 24-h free insulin concentration. The mean blood glucose concentration and HbAlc were almost normalized, and glycaemic control remained improved even after 2-3 years of insulin treatment. A multi-injection regimen, based on preprandial regular insulin and intermediate-acting insulin at bedtime, gave slightly better prandial glycaemic control than a regimen based on twice-daily injections of mainly intermediate-acting insulin, but the overall glycaemic control was similar in both. Insulin treatment reduced the elevated proinsulin concentration that is present in Type 2 diabetes and also lowered the endogenous insulin secretion. The percentage change in blood C-peptide concentration was closely correlated with the percentage change in blood glucose concentration, but not with the percentage change in free insulin concentration. The lipid profile was improved, with marked reduction in the triglyceride-rich lipoprotein concentration and a small increase in HDL cholesterol. Microalbuminuria was reduced and there was no increase in PAI-l antigen concentration. Weight gain occurred during the first year of insulin treatment but not subsequently. Blood pressure was unchanged after 2-3 years of insulin treatment. Severe hypoglycaemic episodes were rare but such can cause cardiac arrhythmia. Patients reported that they felt better.Insulin treatment of patients with Type 2 diabetes and secondary failure to oral hypoglycaemic agents improves glycaemic control and improves or has no adverse effect on the major cardiovascular risk factors.
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| 58. |
- Linnarsson, Rolf
(författare)
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Methods, design and components for a computer-based patient record to promote quality care in general practice
- 1993
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Ever since the introduction of the first computer-based patient records (CPR), there have been expectations concerning the potential of CPR not only to support patient care but also to improve its quality. In this thesis methods and models for CPR in general practice are investigated, particularly with respect to possibilities and limitations concerning quality assurance and decision support.A common thread throughout the thesis is the case of the Kronan Health Centre, where the evolution of a working CPR system in primazy care has been demonstrated. Based on the experiences at Kronan, a conceptual model of CPR has been developed which is aimed at meeting the requirements necessary for a system so that it has the desired impact on quality of care. Three basic components constitute the main part of the model: a patient database, a data dictionary and a medical knowledge base. A structured and standardized CPR is advocated. A controlled medical vocabulary, represented in the model by the data dictionary, is the component that links the patient database and the medical knowledge base together.The empirical part of the thesis is based on two retrospective database studies and two audit studies. In these studies, the primary data source has been the patient database at the Kronan Health Centre, and the primary method of data collection has been database querying using amedical query language. The main empirical results of the studies are: I) There is a relation between diabetes and hypertension (which is in accordance with the hypothesis of a common metabolic syndrome); 2) Potential dmg interacrions occur at a higb rate in general practice, particularly in elderly patients; 3) Medical audit perfurmed with the particular method described can improve patient care within a short term perspective as well as in the long run; 4) Use of CPR facilitates the review of medical records that is needed in audit.A framework for CPR-based quality assurance in primary health care is proposed. The role of CPR within this framework is to facilitate initial and repeated data collection and data analysis and to make feasible an integration of a quality system into routine practice. Based on the conceptual model and on the implications of the empirical studies, a CPR system with integrated decision support has been developed and implemented at the Kronan Health Centre. Decision support has been focused on the real needs of the practitioners and on management rather than diagnosis. Computer reminders related to drug prescribing and computerized care protocols constitute the concurrent audit part of the quality system.
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| 59. |
- Ljungquist-Höddelius, Pia
(författare)
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Biophysical studies of cell membrane receptors for the growth factors PDGP and EGF : Aspects on lateral and aggregation
- 1994
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- When extracellular growth factors bind to their specific cell surface receptors, they elicit a cascade of biochemical events, including tyrosine kinase-mediated phosphorylation and changes in intracellular free ca2+, leading to cell differentiation and proliferation. However, direct effects of ligand-binding on the receptors are poorly understood. This thesis is aimed at investigating the dynamics of growth factor receptors in human fibroblasts after ligand binding, viz. the platelet-derived growth factor (PDGF), and after addition of serum. The effect of ultraviolet B (UV-B) irradiation on the lateral mobility of epidermal growth factor (EGF) receptors was assessed in fibroblasts and keratinocytes.Two techniques were mainly employed to study receptor dynamics. Lateral mobility of receptors was measured with fluorescence recovery after photobleaching (FRAP), and receptor aggregation was analysed with a novel technique, image correlation spectroscopy (ICS), based on confocal laser scanning microscopy.The results, obtained with FRAP for the lateral mobility of the WGA-labelled glycoconjugate and PDGF receptors showed, that: i) the diffusion rate (D) and mobile fraction (R) of the PDGF-receptors depend on the growth conditions, viz. absence or presence of serum in the growthmedium, and stimulation with PDGF or serum. In general, serum increased both D and R in serum-starved fibroblasts, whereas PDGF alone did not change the mobility to any appreciable extent; ii) inhibition of tyrosine kinase using an inhibitor (Erbstatin analog) gave only a slightalteration of the lateral mobility achieved with serum or PDGF addition; iii) UV-B irradiation, noxious to skin cells, caused higher diffusion rate and mobile fraction of EGF-receptors, but in combination with the antioxidant enzymes, superoxide dismutase (SOD) and catalase (CAT), the effects on D and R were counteracted; i v) modulation of ca2+ extraand/ or intracellularly, strongly affected the lateral diffusion of PDGFreceptors, as well as the response to PDGF and serum. In cells depleted intracellulary of ca2+ with a calcium chelating agent, D was reduced about 2-fold compared to control cells; after addition of serum or PDGF D increased again. When extracellular ca2+ was chelated with EGTA, R increased. In cells intra- and extracellularly depleted of ca2+, D wasslightly lower and R higher compared to the controls. In this case PDGF had no effect , whereas serum increased D and R dramatically.In the aggregation studies, using the novel ICS method for quantifying the aggregation state of the receptors, it was found that the surface density of the PDGF receptor clusters decreased when the temperature was raised from 4 oc to 37°C, viz. the density of the clusters was about 3-4 fold lower at 37°C than at 4°C. Tyrosine kinase inhibition with Erbstatin analog seemed to induce receptor dispersion, since the cluster density was several fold higher than without Erbstatin analog. PDGF did not induce further clustering at 37°C. PDGF partly abolished the dispersion effect of Erbstatin analog, in agreement with the involvement of tyrosine phosphorylation in PDGF stimulation of cells.
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| 60. |
- Lundquist, Per
(författare)
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Determination of cyanide and thiocyanate in humans
- 1992
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Cyanide exposure from several sources may cause chronic diseases or acute lethal intoxication in humans. Accurate and specific methods for determination of cyanide and its metabolite thiocyanate are therefore needed for clinical and epidemiological purposes. An improved method for determination of thiocyanate in serum and urine was developed by adsorption of thiocyanate on a weakly basic anion-exchange resin by a chaotropic effect, followed by colorimetrical determination by a modified Konig reaction. Dietary intake of cyanide and sulfur was estimated by determination of urinary thiocyanate and inorganic sulfate in a Mozambican population affected by the paralytic disease konzo. Konzo was found to be associated with a high cyanide and low sulfur intake from a diet dominated by cassava roots that were consumed without removal of the naturally occurring cyanogen compounds. A low intake of sulfur containing proteins was supposed to enhance toxic effects of cyanide by reducing cyanide to thiocyanate conversion.For determination of blood cyanide in field studies an analytical method that enabled transport of samples was developed. Cyanide was stabilized in blood by adding silver ions and after distillation determined by the Konig reaction. A 30-fold increase in sensitivity was obtained by fluorometric determination of the Konig chromogen, which enabled determination of physiological blood cyanide levels 0.117 ± 0.038 J..Ullol/L (mean± SD), and blood cyanide after smoking a cigarette 0.424 ± 0.173 f.tmol/L. A rapid method for determination of toxic blood cyanide levels could be developed by separating the cyanide containing erythrocytes from thiocyanate containing plasma by washing with saline and thereafter protein precipitation followed by direct spectrophotometric determination of the König chromogen.Measurement of hydrogen cyanide in breath showed no correlation with blood levels of cyanide. Experiments revealed that most of the hydrogen cyanide found in breath from normal human beings originates from oxidation of thiocyanate by salivary peroxidase in the oropharynx.In a study of fire casualties 9 out of 18 victims had toxic blood cyanide levels (> 40 J..Ullol/L) and one had a blood cyanide level of 101 J..UllOI/L but a nontoxic blood carboxyhemoglobin, which suggests a lethal effect of cyanide exposure. Blood cyanide levels in two suicidal intoxications were found to be 105 and 139 J..UllOl/L. A lethal outcome in one of the cases that received insufficient antidotal treatment indicates that immediate laboratory verification of cyanide intoxication may be life-saving.
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