Biomedical subjects
Publications and source records attributed to M Cohen.
Cesarean section performed because of fetal distress routinely leaves the fetus unmonitored for a variable period of time (perioperatively and intraoperatively). We present in this report two cases in which continuous fetal heart rate monitoring during cesarean section modified the obstetric management for the benefit of the mother and of the fetus.
Twelve fetuses in whom the diagnosis of fetal distress was made during first stage of labor were included in the study. All 12 patients underwent urgent cesarean section during which fetal heart rate (FHR) was recorded continuously. In 50% of the cases, marked improvement of FHR was registered early in the course of the operation. Improvement in fetal status is attributed to adequate oxygenation and cessation of uterine activity.
A group of 40 select men were studied to assess the value of transrectal ultrasound in the early detection of prostate cancer. All had a benign digital rectal examination and had either irritative lower tract symptoms, hematospermia, microhematuria, or an elevated acid phosphatase. Of the men, 28 had an abnormal ultrasound and underwent a directed prostate needle biopsy to assess the ability to detect clinical Stager A cancer. Eleven men (40%) were found to have cancer, all having hypoechoic lesions. The remainder were found to have benign prostatic hypertrophy (BPH) with hyperechoic lesions predominating (88%). Our results suggest that transrectal ultrasound is a useful and sensitive method for the detection of prostate tumors not clinically evident on digital rectal examination in select patients.
Malignant luteinized thecoma is an extremely rare ovarian tumor. The fifth reported case of this tumor presenting in a 13-year-old epileptic child on anticonvulsant therapy with a rapidly enlarging pelvic-abdominal mass is discussed. At laparotomy, bilateral ovarian involvement, massive ascites, and omental and bowel serosal metastases were present. The pathological diagnosis was difficult with initial diagnoses of ovarian edema, endodermal sinus tumor, and ovarian fibrosarcoma. The final diagnosis of malignant luteinized thecoma was made by recognizing the presence of lutein cells with foamy vacuolated cytoplasm and intracytoplasmic staining for oil red O. Electron microscopy also demonstrated vacuolated cells with multiple fat globules. After surgical debulking the patient was treated with combination chemotherapy with complete response. The similarities of this case to three previously reported bilateral thecomas presenting in children on anticonvulsant therapy is discussed.
The change in left ventricular ejection fraction from preintervention to predischarge was prospectively assessed in 393 patients with acute myocardial infarction. Within 12 h of symptom onset (mean 6.3 +/- 2.7 h), patients were randomly assigned to a double-blind intracoronary infusion of streptokinase, nitroglycerin, both streptokinase and nitroglycerin or conventional therapy without acute cardiac catheterization. Treatment effects were also assessed in prospectively defined angiographic subsets. There was a significant interaction between streptokinase and nitroglycerin (p less than 0.01), resulting in an increase in ejection fraction of 3.9 percentage units in the combined treatment arm (p less than 0.001). Patients with collateral flow to a totally obstructed infarct-related artery showed a significant improvement over those without collateral flow in the streptokinase (5.4 +/- 2.5%) and streptokinase-nitroglycerin (10.6 +/- 2.7%) arms, but not in the nitroglycerin arm. Time to treatment did not influence the change in ejection fraction. In patients with initial subtotal occlusion, thrombolytic therapy was of no short-term benefit because ejection fraction increased by 6% in all three intervention arms. These findings indicate that relatively late thrombolytic therapy results in significant myocardial salvage in those patients with collateralized total coronary occlusion. This benefit is potentiated by concomitant nitroglycerin therapy.
Platelets interact with the coagulation and fibrinolytic systems in the maintenance of hemostasis. However, these physiologic mechanisms may become pathologic, requiring prevention and treatment. In this review, the following clinical developments are analyzed: 1) the role of platelets in thrombogenesis; 2) the pharmacology of platelet inhibitory agents; and, most important, 3) the results of recent randomized trials of platelet inhibitor agents in different cardiovascular disorders. Aspirin reduces mortality and infarction rates in unstable angina and significantly decreases vascular mortality in acute myocardial infarction. Platelet inhibitors decrease mortality and recurrent cardiovascular events in the chronic phase after myocardial infarction. They also decrease vein graft occlusion rates after coronary bypass surgery. Although platelet inhibitors are beneficial in preventing acute vessel occlusion during coronary angioplasty, they are ineffective in preventing chronic restenosis. Antiplatelet agents, combined with warfarin, reduce thromboembolic events in patients with a mechanical prosthesis. Platelet inhibitors are also effective in secondary prevention of vascular events in patients with cerebrovascular disease. Finally, the use of aspirin for primary prevention of cardiovascular disease is still evolving, particularly in individuals at high risk. In conclusion, platelet inhibitors are effective in patients with a variety of cardiovascular disorders. The best studied, most inexpensive and least toxic agent is aspirin at a daily dose of 160 to 325 mg. Studies using new platelet inhibitor agents with different mechanisms of action are currently underway.
Higher grades of collateral circulation limit the extent of myocardial ischemia observed during balloon inflation in patients with single vessel coronary disease undergoing coronary angioplasty. However, the grade of collateral filling during sudden coronary occlusion varies from patient to patient. To assess which characteristics may predict a high grade of collateral filling, baseline clinical and angiographic variables were correlated with the grade of filling during coronary occlusion in 67 patients (whose angina ranged from 1 week to 36 months in duration) undergoing left anterior descending or right coronary artery angioplasty. A second contralateral arterial catheter was used to assess the collateral filling that reached the vessel dilated before and during transient total occlusion by the angioplasty balloon. Thirty-six patients had a proximal stenotic lesion ranging in severity from 65 to 99%. On a 0 to 3 scale, mean collateral filling grade before inflation was 0.4 versus 1.8 during inflation (p = 0.001). All 19 patients with 95 to 99% stenosis had at least grade 2 collateral filling during inflation. In contrast, 18 of 21 patients with less than or equal to 80% stenosis had only grade 0 or 1 collateral filling during inflation. There were significant positive correlations between collateral grade during inflation and 1) baseline lesion severity (r = 0.76), 2) baseline collateral filling grade (r = 0.50), and 3) vessel dilated. There was no relation between collateral filling during inflation and age, gender, risk factors, duration of angina or proximal versus distal location of the lesion. Lesion severity was the only independent variable associated with collateral filling grade.(ABSTRACT TRUNCATED AT 250 WORDS)
We treated three children with renal failure and chronic iron overload with intraperitoneal deferoxamine therapy. Each child had an elevated serum ferritin level, a dense liver as measured by computerized tomography (Hounsfield Units) and one had dialysis related porphyria cutanea tarda. Deferoxamine therapy (10 to 17.5 mg/kg) was given in the overnight exchange for three to six months. Prior to therapy, iron was not detected in the dialysate; during the course of therapy, daily dialysate iron removal averaged 5652 micrograms, 2241 micrograms and 4028 micrograms in the three children. The serum ferritin level fell during the course of therapy in two children who were estimated to be in negative iron balance, and was unchanged in the third who was estimated to be in positive iron balance due to frequent transfusions. In 10 children with chronic renal failure, there was a linear correlation (r = 0.855; P less than 0.01) between the serum ferritin and the liver density, suggesting that an increased serum ferritin correlates with hepatic iron content. Interestingly, in each of the three children who received deferoxamine therapy, the liver density increased during therapy regardless of the estimated iron balance and the change in the serum ferritin level. We conclude that intraperitoneal deferoxamine therapy results in substantial iron losses in peritoneal dialysate, can result in negative iron balance but, in this study, did not result in lower liver iron content as measured by density on computerized tomography scan.
A nematode larva undistinguishable from Dioctophyme renale was found in the subcutaneous tissues of the abdomen of a 23-year-old woman from Ohio. This is the third case of Dioctophyme larva reported in humans. Although it is not known how the infection was acquired, we suggest that ingestion of raw fish was the probable source. We further hypothesize that such a larva could eventually migrate to the kidney and grow to the adult state.
Prolonged vascularized organ allograft survival and an improved quality of life are now possible for many transplant recipients. These advances are due largely to greater understanding of the immune response, the development of potent immunosuppressive agents (cyclosporin A), and improved surgical techniques. Thus more of these patients may require surgical procedures related or unrelated to their original operation, and the plastic surgeon, among other specialists, should be aware of the special problems of the immunocompromised transplant recipient who needs to undergo reconstructive surgery. We report our experience with 15 kidney, heart, and liver transplant recipients who required reconstructive surgery for a variety of conditions. The combined team approach by reconstructive and transplant surgeons is described, as well as the perioperative drug protocol and the special problems that immunosuppressed transplant recipients present. We conclude that these patients can successfully undergo major reconstructive procedures as long as the plastic surgeon not only performs technically flawless surgery, but also familiarizes himself or herself with the special problems of the immunosuppressed host, including the ever-present risk of sepsis and delayed and impaired wound healing, the potential for acute Addisonian crisis, and the possibility of multiple complicating comorbid conditions.
Secondary bone grafting of alveolar clefts has become a well-established procedure. However, little attention has been given to the soft-tissue coverage of these grafts. We present our experience with 32 patients in which gingival mucoperiosteal flaps were used exclusively in conjunction with bone grafting for patients with residual alveolar clefts. The indications and timing of the procedure as well as the steps of the technique are presented. The advantages of bone grafting at the stage of mixed dentition and the superiority of gingival mucoperiosteal flaps, including teeth eruption through the graft, additional teeth support, dental hygiene and aesthetic appearance of the alveolar ridge, are discussed. Our results are compared with those obtained with similar or other techniques.
After intravenous infusion of secretin and cholecystokinin in six dogs, cefamandole (50 mg/kg of body weight) was given intravenously for 10 min. Samples of serum, bile, pancreatic juice, liver, pancreas, fat, and muscle were collected over a 2-h period. Cefamandole levels were measured by a microbiological assay. The highest levels were as follows: serum, 160 micrograms/ml; bile, 3,071 micrograms/ml; pancreatic juice, 7 micrograms/ml; liver, 101 micrograms/g; pancreas, 44 micrograms/g; muscle, 20 micrograms/g; and fat, 14 micrograms/g. Levels in pancreatic juice were extremely low compared with levels in pancreatic tissue, suggesting the existence of a barrier to excretion at the ductal membrane.
The long-term clinical course was studied in 646 patients, who underwent isolated operative repair of coarctation of the aorta at the Mayo Clinic from 1946 to 1981. There were 17 perioperative deaths, and 58 patients were lost to follow-up. Of the 571 patients with long-term follow-up, 11% required subsequent cardiovascular surgery, and 25% developed hypertension. There were 87 late deaths. The mean age at death was 38 years (range, 0-67 years). Estimated survival analysis revealed 91% of patients alive at 10, 84% at 20, and 72% at 30 years after operative repair. The most common cause of late death was coronary artery disease in 32 patients, followed by sudden death, heart failure, cerebrovascular accidents, and ruptured aortic aneurysm. Age, sex, and postoperative systolic blood pressure were found to be independently predictive of survival. For patients less than 14 years of age at the time of initial coarctectomy, survival to 20 years was 91%, and for patients 14 years or older at the time of operation, survival was 79%. The best survivorship was observed in patients operated on at 9 years of age or less. The higher the postoperative systolic pressure, the higher the probability of death. This study has the largest population undergoing repair of coarctation of the aorta with a median follow-up of as long as 20 years. Four main points emerged. 1) Age at the time of initial repair is the most important predictor of long-term survival. Surgery should be offered to patients after age 1 year or sooner if hypertension is severe. 2) Coronary artery disease is the most common cause of late death.(ABSTRACT TRUNCATED AT 250 WORDS)
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Sexual concerns are common and opportunities for general practitioners to deal with them are numerous. This paper discusses the range of opportunities for providing sex education, anticipatory counselling and appropriate therapy in the context of the usual activities of general practitioners. Some of the requirements to fulfil this role effectively are identified.
We present a family in which chromosomally normal parents have had two different structurally abnormal pregnancies. These rearrangements have both been in the mosaic form with a normal cell line. Various mechanisms for this rare situation are discussed.
In an effort to account for the effects of both physician and patient characteristics in understanding difficult physician-patient relationships, family physician participants in the Michigan Research Network, a practice-based research network in the state of Michigan, were assessed for their perceptions of "difficult" patients. Twenty-two family physicians responded to a mail survey in which they selected from among their respective practices a sample of patients whose care they considered to be particularly difficult. This sampling procedure resulted in a total of 205 difficult patients. Physicians' perceptions of these patients were obtained through ratings of the applicability of 40 behavioral and physical characteristics drawn from the literature. Factor analysis of these data resulted in the identification of two factors underlying physicians' perceptions of difficult patients: medical uncertainty, characterized by particularly vague, difficult to describe, undifferentiated medical problems; and interpersonal difficulty, reflected in a perceived abrasive behavioral style. In addition, physicians self-rated the importance of various motivations for practicing medicine. The top six ranked mean ratings indicate that the primary motivations for practicing medicine were satisfaction derived from solving medical problems and the desire to help people. The interaction of these physician and patient characteristics is offered as a partial explanation for the development of difficult physician-patient relationships.