Coronary sinus thrombosis and myocardial infarction secondary to ventriculoatrial shunt insertion

Coronary sinus thrombosis was found at necropsy in a girl with spina bifida who underwent ventriculoatrial shunt revision. There was secondary myocardial infarction, close to the conducting system within the interventricular septum. We suggest that this led to cardiac arrest and sudden death.     

Ambulatory 24-hour esophageal pH monitoring

If 24-hour esophageal pH monitoring is to be a useful diagnostic tool, it must reliably discriminate gastroesophageal reflux patients despite daily variations in distal esophageal acid exposure. To address this issue, we studied 53 subjects (14 healthy normals, 14 esophagitis patients, and 25 patients with atypical symptoms) with two ambulatory pH tests performed within 10 days of each other. Intrasubject reproducibility of 12 pH parameters to discriminate the presence of abnormal acid reflux was determined. As a group, the parameters of percent time with pH<4 (total, upright, recumbent) were most reproducible (80%). Therefore, a subject was defined as having gastroesophageal reflux disease if at least one of these three values were abnormal. Intrasubject reproducibility for the diagnosis of reflux disease was 89% for the entire sample. Among subsets, the reproducibility was 93% for the normals and esophagitis patients and 84% for the atypical symptom patients. Total percent time with pH<4 was the single most discriminate pH parameter (85%) and nearly equaled that of the three combined parameters (89%). The intrasubject variability of this parameter was determined by the mean ±2sd of the relative differences between the two test results for all 53 subjects. Total percent time with pH<4 may vary between tests by a factor of 3.2-fold or less (218% higher to 69% lower). We conclude: (1) ambulatory 24-hr esophageal monitoring is a reproducible test for the diagnosis of gastroesophageal reflux disease; and (2) the large intrastudy variability in 24-hr total acid exposure may limit this test's usefulness as a measurement of therapeutic improvement.Supported, in part, by Public Health Services Grant AM 34200-01A1 from NIADDIK.     

A prospective, randomized, cross-over comparison of two methods of artificial insemination by donor on the incidence of conception: intracervical insemination by straw versus cervical cap

In a prospective, randomized study of insemination with donor semen, intracervical insemination by straw was compared with insemination using a cervical cap with an intracervical reservoir. A total of 91 patients completed 486 treatment cycles. There were no significant differences in age, parity, indication for insemination by donor, or method of cycle monitoring between women who became pregnant and those who did not conceive with either insemination method. In 236 standard intracervical insemination cycles, 14 patients became pregnant (5.9% per cycle), whereas 38 patients conceived in 250 cervical cap cycles (15.2% per cycle). Both the crude pregnancy rates and the cumulative pregnancy rates calculated by the Kaplan-Meier life-table method were significantly different (chi(2)-test, P < 0.001, and log-rank test, P < 0.005 respectively). Pregnancy rates in artificial insemination with cryopreserved donor semen may be improved by the use of a cervical cap when compared to cervical insemination by straw. The use of the cervical cap may prolong the exposure of the spermatozoa to the cervical mucus and prevent the backflow of semen into the vagina.      

Surgical management of facial palsy

Patients with facial palsy present with a multitude of different problems to which individual solutions must be carefully tailored. Although numerous surgical options exist, the results of reconstruction are rarely ideal. This article discusses different surgical procedures for reconstruction of the eye and mouth with special emphasis on the newer technique of microsurgical transfer of muscle tissue for reanimation.     

Temporomandibular joint arthrography following surgical treatment of internal derangements

Arthrograms of the temporomandibular joint were obtained in 20 symptomatic joints that had previous reconstructive arthroplasty with disk repositioning because of internal derangements. Preoperative arthrograms were available for comparison in 18 joints. Symptoms resulting in a postoperative arthrogram included pain, limited ability to open the mouth, and clicking of the joints. Postoperative arthrographic findings included limited anterior translation of the condyle (90%), irregularity in outline of the intraarticular contrast agent (60%), a conical configuration of the posterior recess (25%), decreased size of the joint (28%), anterior displacement of the meniscus (25%), and perforated meniscus (15%). Many of these findings may have resulted from fibrosis and scarring, which may be a response to intraarticular bleeding. The mechanism by which the fibrosis causes the postsurgical arthrographic features is discussed.     

Renal vein renin analysis: Limitations of its use in predicting benefit from percutaneous angioplasty

Two hundred forty-four consecutive patients (mean age 61 years), including 123 who had technically valid renal vein renin (RVR) analysis and 121 without RVR data, underwent technically successful percutaneous renal artery angioplasty (PTRA). They were retrospectively examined to evaluate the utility of RVR analysis in identifying renal hypertension (RVH), predicting benefit from PTRA, and determining if the lack of knowledge of renin levels significantly affected clinical outcome after PTRA. Abnormal RVR values were associated with clinical benefit after PTRA in 62 of 93 patients (67% sensitivity, 20% specificity, 72% positive predictive value). Clinical improvement following PTRA occurred in 31 of 37 patients with normal pre-PTRA RVR values (16% negative predictive value). RVR analysis correctly identified 86 of 117 patients with renovascular hypertension (74% sensitivity, 16% negative predictive value). Improved blood pressure (BP) control occurred in 72% with abnormal RVR analysis and 66% of the 121 patients without RVR data (p>0.1). We conclude that the very low negative predictive value significantly limited the use of RVR analysis in this elderly (mean age 60 years) patient population with a high incidence of mild renal functional impairment (mean serum creatinine 1.4 mg/dl) and bilateral renal artery stenosis (38%). The lack of pre-PTRA renin data did not significantly affect clinical outcome. If RVR data were relied upon as the exclusive selection criterion in patients of this type, many would be prevented from having the benefit of cure or improvement by PTRA.     

Bronchiectasis following colectomy for Crohn's disease

Bronchiectasis developing following colectomy for ulcerativecolitis has been reported in a few cases. This may be the first reportof bronchiectasis developing after colectomy for Crohn's disease. Theclose temporal relationship to colectomy, lack of bacterial pathogensin the sputum, and an impressive response to oral steroids suggest adifference in pathogenesis from idiopathic bronchiectasis.

     

Choosing drug use measures for treatment outcome studies. II. Timing baseline and follow-up measurement

The use of different approaches to measurement in drug abuse treatment outcome studies has resulted in a lack of comparability across studies. This paper reviews different approaches to timing of baseline and follow-up periods and to dealing with time periods during which follow-up subjects are not "at risk" for drug use. Length and timing of baseline and follow-up periods are considered as well as periods of time within which specific drug use outcomes are measured. It is suggested that research focus on describing the natural course of drug use both prior to and following treatment, in order to determine the most appropriate length and timing of follow-up periods. It is recommended that investigators report drug use data from both "at risk" and "not at risk" periods, and that they choose methods of controlling for time "at risk" which do not eliminate important drug use data from analyses.     

Detection bias in the diagnostic pursuit of lung cancer

Autopsy studies have shown that lung cancer is often not detected during life and that a correct antemortem diagnosis is made preferentially in patients with pulmonary symptoms, in smokers, and in men. The current research was done as a case-control study to determine whether the autopsy suggestions of detection bias in diagnostic pursuit of lung cancer were confirmed by the way that sputum Papanicolaou smears (Pap smears) were ordered in an inpatient setting. The cases were 385 hospitalized patients in whom sputum Pap tests had been newly performed from October 1977 to September 1980. Each case was matched by age, admission date, and admission diagnosis to a control patient who had not received a Pap test. Excluded from the study were patients in whom sputum Pap tests were obligatory (e.g., those with manifestations of hemoptysis) or unnecessary (e.g., those with a previous diagnosis of lung cancer or multiple previous sputum Pap tests). Demographic data, amount and duration of cigarette smoking, and details of clinical manifestations were extracted from the patients' medical records by research assistants blind to the study hypothesis. Compared with controls, the cases had distinctive elevations in odds ratios for chronic cough, recent cough, male sex, and cigarette smoking, which also showed a distinctive dose-response relation. In multivariate analyses, all four of these "risk factors" for selective ordering of a sputum Pap smear remained independently highly significant. In the extreme category, men who smoked and coughed were 22 times more likely to have a sputum Pap test ordered than were nonsmoking women who did not cough. Clinically, the results suggest that women and nonsmokers may be deprived of appropriate diagnosis and therapy unless a diagnostic workup for lung cancer is guided mainly by radiographic findings and presenting manifestations. Statistically, detection bias has probably led to an excessively elevated magnitude for the cigarette smoking-lung cancer association and to a falsely low estimate of incidence rates in women.