Assessing the diagnostic accuracy and efficacy of selected antepartum fetal surveillance techniques

Published studies on the contraction stress test (CST), the nonstress test (NST), and monitoring of fetal movement were reviewed to assess the accuracy and efficacy of these techniques. The false-negativity and false-positivity rates, sensitivity, and specificity of these tests were assessed with use of perinatal mortality and various measures of morbidity as outcomes. Both the CST and the NST generally demonstrated low sensitivity and high rates of false positivity. No randomized controlled trials have been conducted that are of sufficient size to demonstrate whether there is a significant difference in outcome following use of the CST or the NST. A single nonrandomized, controlled trial evaluating fetal-movement monitoring suggested clinical benefit. Direct costs of NSTs and CSTs in the United States were estimated to exceed $200 million per year. Yet the CST and the NST have not been demonstrated to be useful diagnostic tests. The CST, the NST, and fetal-movement monitoring are potentially useful screening tests. However, they require critical evaluation, with large randomized, controlled trials, to determine their efficacy and safety before their further diffusion into obstetrical practice.     

Assessment of the Denham knee replacement. Results after eight years

The Denham knee replacement is a relatively simple unconstrained prosthesis. The design ensures good alignment and full extension, but does not allow flexion beyond 90 degrees or tibiofemoral rotation. The results after eight years' experience have been assessed in four different ways in over 600 cases. They show that for the limited needs of the elderly arthritic patient, the Denham arthroplasty provides a high proportion of satisfactory results with an unusually low rate of late failure.     

Cervical internal carotid artery dissecting hemorrhage: diagnosis using MR

Two men underwent high-resolution magnetic resonance (MR) imaging of the internal carotid artery (ICA) 12 and 16 days after spontaneous dissection of this vessel. One underwent follow-up MR imaging 7 weeks later. T1-weighted images were obtained in both cases, and T2-weighted images were obtained in one patient. In both cases, the MR findings corresponded to the angiographic abnormalities. On both the T1- and T2-weighted images, there was a hyperintense lesion expanding the wall and narrowing the lumen of the ICAs. Follow-up MR imaging showed complete resolution of the mural lesion. Axial images best demonstrated the anatomic and MR signal alterations. The hyperintensity of the lesion on both T1- and T2-weighted images indicated a short T1 and a long T2 as expected in a subacute hematoma. High-resolution MR imaging, therefore, can specifically demonstrate a thrombosed carotid dissection noninvasively at least as early as 12 days. The potential to diagnose carotid dissection in the acute phase using high-field-strength MR imaging and its importance for the prevention of embolic strokes are also discussed.     

Fluorotic radiculomyelopathy in a Libyan male

A middle-aged male resident of Benghazi, northeastern Libya, with radiological features of skeletal fluorosis associated with cervical radiculomyelopathy is reported. This is believed to be the first documentation of such a disorder from this non-tropical, non-endemic region.     

Superior oblique muscle involvement in thyroid ophthalmopathy.

BACKGROUND: Rectus muscle involvement in thyroid ophthalmopathy is well documented. The inferior rectus is the most frequently involved, followed by the medial, superior, and infrequently the lateral rectus. This study reports involvement of the superior oblique muscle as a contributory cause of restrictive strabismus in patients with thyroid ophthalmopathy. METHODS: This is a retrospective review of four patients with known thyroid ophthalmopathy who presented with incomitant vertical strabismus, A-pattern, overdepression in adduction, underelevation in adduction, and incyclotorsion. All patients underwent preoperative orbital imaging. Two of the four patients had previous orbital decompressions. All patients underwent surgery on the SO muscle. RESULTS: Preoperative scans showed enlargement of one or both SO muscles in all patients and intraoperative forced duction testing revealed restriction to elevation in adduction in all cases. Preoperative A-pattern ranged from to 6 to 22 prism diopters. All subjects had preoperative incyclotorsion, ranging from 2 and 14 degrees. Improvement of the versions, hypertropia, and cyclotorsion followed surgical weakening procedures on the SO muscle. CONCLUSION: Thyroid ophthalmopathy may involve the SO muscle. Clinical manifestations include preoperative A-pattern strabismus, incyclotorsion, and restrictive limitation to elevation in adduction. Orbital imaging documents SO muscle enlargement. Awareness of SO involvement in thyroid ophthalmopathy assists the surgeon to develop a more precise surgical strategy to correct the hypotropia.     

Biochemical performance of tapercut cardiovascular needles

Standardized reproducible tests have been developed to determine the biomechanical performance of cardiovascular needles. The parameters used to assess performance were: 1) sharpness, 2) resistance to bending, and 3) ductility. Four comparable groups of tapercut and taper point cardiovascular needles were selected from different manufacturers for these biochemical studies. The results of this testing demonstrated that needle geometry, needle composition, and the manufacturer were important determinants of needle performance. When comparable needles were evaluated, the biochemical performance of cardiovascular needles manufactured by Ethicon, Inc. (Somerville, NJ) were superior to needles produced by other manufacturers. The superior performance characteristics of the cardiovascular needles produced by Ethicon, Inc. were related to their unique stainless steel alloy, American Society for Testing Materials 45500, which has greater yield and tensile strengths than the alloy used by the other manufacturers. This stainless steel alloy was ideal for the production of tapercut needles, which combined some of the features of a reverse cutting edge needle and taper point needle. Its very short cutting edges allowed it to penetrate the membrane at considerably lower penetration forces than were encountered with comparable taper point needles. In addition, the investigation indicated that the trocar point cardiovascular needles produced a large triangular defect whose diameter was much larger than that of the needle body. For this reason, the use of the trochar point needle is not recommended in cardiovascular surgery.     

Occult cerebral vascular malformations: high-field MR imaging

Occult cerebral vascular malformations (OCVMs) have characteristic appearances on high-field magnetic resonance (MR) images. These consist of circumscribed regions of low intensity, most prominent on T2-weighted images and representing hemosiderin deposits. Interspersed within most of these lesions are multiple areas of various signal intensity patterns, which correspond to hematomas in different stages of evolution and to fibrous regions containing calcium as well as hemosiderin. Forty-six lesions were found in 19 patients (34 supratentorial and 12 infratentorial). The supratentorial lesions tended to be subcortical or periventricular. Computed tomography depicted 24 of the 46 lesions demonstrated by high-field MR. Comparison of images obtained with both low-field MR (0.12 T and 0.35 T) and high-field MR (1.5 T) revealed that high-field MR imaging was superior in depicting OCVMs. High-field MR appears to be both sensitive and specific for OCVMs and may obviate the need for possible biopsy of these lesions.     

Measuring health program effectiveness in the field: an assessment tool

To assist field workers in program evaluation and to explicitly discuss program strengths and weaknesses, a practical method to estimate the effectiveness of public health interventions within the existing program capacity was developed. The method and materials were tested in seven countries (Afghanistan, Zimbabwe, Tanzania, Uganda, Guatemala, the Philippines, and Ghana). In this method, four core components are assessed using a questionnaire: (1) the efficacy of the intervention; (2) the level of existing human resources (i.e., quality of recruitment, training, and continuing education); (3) the infrastructure (i.e., supplies, salary, transportation, and supervision); and (4) the level of community support (i.e., access and demand). Using the assessment tool provided, program staff can determine if all necessary elements are in place for a successful program that can deliver the specific intervention. Based on the results of the assessment program, weaknesses can be identified, explicitly discussed, and addressed. The usefulness of this tool in humanitarian relief may be twofold: (1) to assess the design and implementation of effective programs; and (2) to highlight the inevitable need for capacity building as the disaster situation evolves.