Ureteral stenting during extracorporeal shock wave lithotripsy: help or hindrance?

We retrospectively reviewed the outcome of extracorporeal shock wave lithotripsy in patients with renal calculi less than 3 cm. in size who were treated at a large multi-user lithotripsy center. Patients in whom indwelling ureteral stents were placed before lithotripsy treatment were subjected to higher levels of total power (shocks times voltage), yet the rate free of stones did not differ from those treated without a stent. In addition, the patients with internal ureteral stents experienced a significantly higher incidence of urinary urgency (43 versus 25 per cent) and hematuria (40 versus 23 per cent) than nonstented patients, respectively (p less than 0.05). Also, the duration of bladder discomfort was longer for stented patients (26 versus 13 per cent) as was the duration of urinary frequency (31 versus 16 per cent), compared to nonstented patients (p less than 0.05). The results suggest that use of an indwelling ureteral stent may not contribute to a higher rate free of stones for the treatment of small to medium sized renal calculi and, in fact, it may make the treatment more uncomfortable for the patient than performing lithotripsy without ureteral stenting. Of course, in selected cases (solitary kidney, large stone burden and aid in stone localization) ureteral stenting has a useful adjunctive role in extracorporeal shock wave lithotripsy.     

Diagnosis of a persistent pulmonary embolus by Indium-111 platelet scintigraphy with angiographic and tissue confirmation

We describe a patient with an acute and persistent pulmonary embolus, identified after five weeks of heparin therapy (25,000 IU per day, administered intravenously) by indium-111 platelet scintigraphy. The diagnosis was confirmed by pulmonary angiography and later at surgery. Platelet scintigraphy convincingly demonstrated the continual uptake of platelets onto the surface of the thrombus despite anticoagulant therapy. It might provide a noninvasive means of identifying nonresolving pulmonary emboli.     

Introductory course in biomedical ethics in the obstetrics-gynecology residency

Teaching biomedical ethics to physicians at the postgraduate level is difficult because of the time constraints in residency training programs. The author here describes the information used in a brief lecture that introduces a biomedical ethics curriculum in an obstetrics and gynecology residency.     

City directories as sources for survey work in low- and middle-income black communities.

Commercial directories and governmental lists of dwelling units in low income urban Black communities in four eastern cities were evaluated for completeness. With rare exceptions, less than 90 percent of dwelling units were included in any one list and no list adequately identified multiple dwelling unit structures. Since household income is likely to be lower among households in such structures, all lists tend to miss the very poor, i.e., those who may be at highest health risk.     

Preoperative coronary artery bypass grafting in patients undergoing abdominal aortic reconstruction

The effect of preoperative aortocoronary bypass grafting on the operative mortality of patients undergoing elective abdominal aortic reconstruction was examined by reviewing a series of 224 consecutive patients (1980 to 1983) (Group I) in whom selective preoperative noninvasive and invasive cardiac screening was used to identify patients with significant coronary stenoses. One patient died during cardiac catheterization. Twenty-seven patients (12 percent) underwent aortocoronary bypass grafting with one operative death (3.7 percent) and one nonfatal myocardial infarction (3.7 percent). These 26 patients subsequently underwent abdominal aortic reconstruction with no mortality and no postoperative myocardial infarction. One hundred ninety-six patients (88 percent) underwent aortic reconstruction without prior aortocoronary bypass grafting with four operative deaths (2 percent), including two fatal myocardial infarctions. The combined operative mortality for Group I patients was 2.3 percent. Three hundred twenty-six patients (Group II) who underwent abdominal aortic reconstruction at this institution from 1970 to 1976 had an 8 percent operative mortality, of which 50 percent of the deaths were due to myocardial infarctions (Group I versus Group II, p less than 0.01). Selective preoperative screening for coronary artery disease in patients undergoing elective abdominal aortic reconstruction with aortocoronary bypass grafting in selected patients is safe and may help reduce the operative mortality.     

A reconsideration of the relevance of recent animal studies for development of treatment procedures for alcoholics

Amit and Sutherland's conclusions concerning the use of conditioned taste aversions for alcoholism treatment are critically evaluated. Their conclusion that painful electric shock is contraindicated as a basis for alcohol taste aversions is consistent with the animal and human literature which depicts nausea as a more biologically appropriate US for taste aversion formation. However, Amit and Sutherland also conclude that alcoholics will not develop illness-induced alcohol aversions because animal studies show that aversion acquisition is disrupted by preconditioning familiarity with the conditioned stimulus (CS) — flavor — or unconditioned stimulus (US) — illness. This conclusion is untenable because Amit and Sutherland only considered animal conditioning methods that differed markedly from aversion therapy practices. Other animal studies modeled after aversion therapy procedures clearly show CS and US preexposure effects to be transitory phenomena. Moreover, experimental and clinical data show humans to be quite susceptible to taste aversion formation, and that many alcoholics do form strong alcohol aversions under appropriate conditioning parameters. Additional implications of the animal literature for effective aversion therapy are explored, and the paper concludes with a discussion of covert sensitization, a promising verbal aversion therapy which has resulted in the development of strong alcohol aversions in many volunteer subjects at the Augusta Veterans Administration Medical Center.