Gallstone lithotripsy (GSL): results of the Technomed Sonolith 3000 multicenter trials

Gallstone lithotripsy (GSL) with the Technomed Sonolith 3000 extracorporeal lithotripter was studied in a multisite, international cooperative trial involving the United States, France, and Italy. All participating sites worked under a common protocol to investigate the safety and efficacy of GSL for symptomatic gallstone patients. These collective results are from a mix of 25 academic and community hospital sites using fixed and transportable/mobile versions of the lithotripter. As of November 1, 1990, 661 patients have been treated in this two-arm randomized study (GSL Only vs GSL + Ursodiol [Actigall]). Patients were treated with up to 2,500 shocks per session and only two treatments were allowed. All machines had standardized pressure settings (850 bar nominal) and operator adjustment of output voltage was not allowed. We saw no statistically significantly different results in initial fragmentation between patients pre-loaded with ursodiol for 2 weeks and those treated by GSL alone. Gallbladder clearance rates did vary with the stone number, size, and burden as well as the adequacy of initial fragmentation. In the GSL + Ursodiol Arm of the trial, 46.2% of patients with solitary, 5-to 20-mm calculi are stone-free at 6 months.     

A critical analysis of the largest reported mass fecal occult blood screening program in the United States

Fecal occult blood testing for the detection of colon cancer remains controversial. We performed a mass screening program from January 24, 1988, to February 19, 1988, with intensive media promotion, including 121 minutes of televised air time. A total of 5,000 primary practitioners were notified by mail. Hemoccult-II tests were distributed to 156,000 individuals; 55,051 (35%) were returned. Ninety-five percent of the respondents were informed of the program by television. A total of 3,375 persons (6%) tested positive for fecal occult blood; of these, 2,469 (73%) informed the center that they saw their physician to initiate a work-up. Information from physicians regarding work-ups was returned on only 1,356 (55%) patients. Diagnostic tests numbered 2,227 (1.6 tests per patient). However, 5% had no testing, 16% had a repeat Hemoccult only, and 35% had neither a barium enema nor colonoscopy performed. Thirty-six colorectal cancers and 212 polyps were identified. The predictive value (i.e., number of cancers per number of patients who tested positive) increased directly by decade. Thirty-three of 36 patients (92%) with cancer underwent either a barium enema or colonoscopy versus only 185 of 438 (42%) patients with a "negative" work-up. Cancers found were carcinoma in situ in 10 patients (29%), Dukes A in 12 (35%), Dukes B in 4 (12%), and Dukes C in 8 (24%); distant metastases were not found in any participant. Thirty-six percent of the tumors were located in either the right or transverse colon. We conclude that: (1) Screening identified early cancers. All were potentially curable and 64% were limited to the bowel wall. (2) Massive Hemoccult distribution was possible over a short interval, but patient and physician compliance was disturbingly low. (3) Total colonic evaluation is mandatory, since at least 36% of tumors were beyond the reach of the flexible sigmoidoscope. (4) Many work-ups were unnecessary (repeat Hemoccults) or inadequate, indicating a need for physician education.     

Responsibilities and training needs of mental health administrators

This paper reports findings of a needs assessment in the area of training programs for senior mental health administrators. Questionnaires (N=530) were sent; 169 to county and regional state mental health administrators; 331 went to community mental health administrators. The response rate was 43%. Thirty-four percent of the public sector respondents listed general administration as their first topic; fiscal issues were listed by 19%; 18% listed personnel administration first. Second topics chosen for training by the public sector administrators were general administration (17%), financial management (24%), and personnel (20%). As their first topics of choice for future training, 37% of the community mental health administrators selected general administration areas, 27% selected financial management, and 10% personnel. Training for mental health administrators has the potential for substantial enrichment through the design and implementation of carefully planned programs. Results from this needs assessment show the continued strong need for such training.     

Clinical significance of retrograde flow in the vertebral artery

Although retrograde vertebral artery flow was described over 100 years ago, its relationship to symptoms remains unclear. We documented 43 patients who were found by duplex scanning to have reverse flow in the vertebral artery. Of this group, seven patients (16%) were found to have symptoms described as typical for the subclavian steal syndrome. Nearly one-third were asymptomatic. Of the remaining patients, 13 (30%) presented with nonhemispheric symptoms while nine (21%) had hemispheric symptoms. Nine patients had to and fro flow in the vertebral artery. This variant was not found in subclavian steal patients but correlated with nonhemispheric symptoms. During follow-up (mean: 19 months) none of the asymptomatic patients became symptomatic, and there were no strokes or stroke-related deaths. Surgical procedures which restored antegrade vertebral artery flow did not necessarily improve symptoms of posterior circulation ischemia. In some patients improvement in posterior circulation symptoms was noted following carotid endarterectomy. It is concluded that retrograde flow in the vertebral artery is, per se, a benign entity. Accurate selection of surgical candidates remains imprecise. It will require not only identification of vertebrobasilar disease but as yet undefined tests to assure symptoms are due to these stenoses.     

Plastic and Reconstructive Body Contouring in the Post-vertical Banded Gastroplasty Patient: a retrospective review

Class IV obesity (body mass index > 40) is associated with an increased risk of a variety of health problems, many of them potentially life-threatening or life-shortening. Vertical banded gastroplasty (VBG) is currently the most frequently performed surgical procedure used to restrict food intake and assist with weight loss. After massive weight loss, however, redundant abdominal and breast tissue can result in physiological and psychological problems related to an unusual body habitus. Patients complain of difficulties with daily activities, choice of clothing, social acceptance, etc. Body contouring has proven to be an important part of the rehabilitation of the morbidly obese patient, and we have therefore reviewed the records of 55 patients who experienced massive weight loss following VBG and then underwent abdominoplasty with or without mammoplasty/mastopexy, in order to assess the parameters which will be seen more frequently in the future by plastic surgeons as bariatric surgery becomes more widely accepted and performed.     

A distributed approach to integrated inquiry and display for radiology

Picture archive and communications (PACS) systems should be flexible and modular in design so that new advances in storage, computation, and display technology can be introduced into the system without a significant redesign of existing software. The acquisition, storage, and management of radiologic images must be carefully integrated with a radiology information system. Our architecture is based on a four-level data model: (1) patient information, (2) examination information and reports, (3) image information, and (4) instances of images. The PACS being developed at the Mallinckrodt Institute of Radiology within the Electronic Radiology Laboratory consists of three primary components: application clients, database servers and image servers. One type of application client is an image-capable workstation that supports a radiology image viewing application. The application client queries the database server for information regarding patient and examination data in response to user-level requests. The database server responds to the request by retrieving the appropriate patient demographics and examination information, along with a pointer to the image/instance data from a central database. The client then uses the image data pointer to query the image server for the actual pixel data. The image server responds by transmitting the pixel data to the requesting application client or a designated auxiliary display device. Other clients act as image data acquisition nodes. Queries to the database servers are made via a library of callable subroutines. Software integrity is maintained throughout the system by dynamically loading software from a code-control database. Inquiry and display transactions, supported on a local-area network (Ethernet), have been measured and analyzed. Results and observations are presented.     

Sexual orientation and cognitive abilities

We asked whether homosexual and heterosexual men and women differ on standard measures of cognitive ability. Subjects were adults recruited for a family study of sexual orientation. They completed the Fy Scale of the California Psychological Inventory, a self-administered measure of psychological femininity, and were given subtests of the Wechsler Adult Intelligence Scale and the Primary Mental Abilities test which had been previously shown to discriminate between the sexes. We predicted that homosexual subjects would score significantly in the gender-atypical direction on the Fy scale. We also predicted that they would achieve scores on the tests of cognitive abilities significantly in the direction of the other gender. Comparisons were made between homosexual and heterosexual individuals within gender. Also, comparisons were made between heterosexual men and women to see if our results replicate differences typically found between the genders. As predicted, both homosexual men and women were strongly gender-atypical on the Fy scale relative to their heterosexual counterparts. However, neither differed from heterosexuals on any of the measures of cognitive abilities. Heterosexual men did better than women on the Primary Mental Abilities spatial relations test. We conclude that sexual orientation is not related to specific cognitive abilities.Supported in part by NIMH grant 32,170 to Dr. Pillard.     

Extrahepatic bile duct angulation by T-tube: The elbow sign

The normal shape of the extrahepatic bile ducts approximates a straight line. The cholangiograms of 50 patients with indwelling T-tube catheters were retrospectively reviewed between 4 and 14 weeks postcholecystectomy. We observed a lateral distortion in the shape of the bile ducts in 35 patients (70%) such that an angle measured between the proximal and distal parts of the duct, centered at the site of T-tube insertion, decreased to between 60° and 158°. We have called this observation the elbow sign, which to our knowledge has not been previously described and appears to be of no clinical consequence.     

Long-term postthoracotomy pain

We used a pain questionnaire to evaluate the prevalence and functional significance of long-term postthoracotomy pain. Data on 56 patients who were at least 2 months postsurgery were analyzed. Thirty patients (54 percent) with a median follow-up of 19.5 months had persistent pain; 26 others were pain free at a median of 30.5 months postthoracotomy. Pain was reported in 24 of 44 patients (55 percent) who were more than one year after surgery, 13 of 29 patients (45 percent) more than two years, six of 16 (38 percent) more than three years, and three of ten patients (30 percent) greater than four years postthoracotomy. Pain intensity was low, but 13 patients stated that pain "slightly" or "moderately" interfered with their lives. Five of 56 patients had sufficiently severe chronic pain to require either daily analgesic use, nerve blocks, relaxation therapy, acupuncture, or referral to a pain clinic. We conclude that long-term chest wall pain is common postthoracotomy. It is generally not severe, but a small proportion of patients may experience persistent, moderately disabling pain.