123rc/medical_text huggingface dataset:
Minitracheotomy: complications and follow-up with fibreoptic tracheoscopy. Complications and changes in tracheal mucosa after minitracheotomy were evaluated in 28 patients. Tracheal mucosa was inspected fibreoptically after the insertion of a minitracheotomy cannula, and then at 3-day intervals until the cannula was removed. Thereafter, assessments were made every third day until the mucosa was considered normal. Three significant complications occurred: mediastinal puncture, paratracheal entrance of the cannula and subcutaneous emphysema. Difficulties at insertion of the minitracheotomy cannula were encountered in 15 of 28 patients (54%). Air flow detected through the cannula in one patient, and lack of air flow in another patient, were misleading signs of the position of the cannula. Passing a suction catheter in three patients and a normal end-tidal carbon dioxide tracing in one patient, were also found to be misleading. The correct position and possible complications could be verified only by fibreoptic tracheoscopy. Changes in the tracheal mucosa were independent of the duration of minitracheotomy therapy.
The location of the maxillary os and its importance to the endoscopic sinus surgeon. As functional endoscopic sinus surgery continues to gain popularity and support, the necessity for a clear and accurate understanding of the anatomy of the ostiomeatal complex becomes essential. To clarify this anatomy, serial cadaver dissections were performed and the anatomy of the ostiomeatal complex was detailed in three dimensions, with an emphasis on precise localization of the internal os of the maxillary sinus as it relates to the orbit, natural antronasal canal, and ethmoid infundibulum. Measurements of the position of the internal os relative to the position of the anterior and posterior walls of the maxillary sinus and the position of the orbit were taken. The dimensions and configuration of the antronasal canal and its relationship to the infundibulum were also detailed. These measurements and relationships must be understood for an endoscopic sinus surgeon to locate the natural ostia without injuring the orbit.
Facial pain. This article presents differential diagnosis and treatment of facial pain. Facial pain is classified in accordance with the recent work of the Headache Classification Committee of the International Headache Society. The two major divisions are facial pain associated with disorders of the head and neck, including their parts, and disorders of cranial nerves, including their central connections. Special attention is paid to the controversial topics of temporomandibular joint dysfunction and atypical facial pain.
Prokinetic treatment of constipation-predominant irritable bowel syndrome: a placebo-controlled study of cisapride. The effects of prokinetic treatment with cisapride in patients with constipation-predominant irritable bowel syndrome (IBS) were evaluated in a randomized, double-blind, placebo-controlled study. Sixty-nine IBS patients were assigned to a 12-week treatment with either 5 mg cisapride or placebo t.i.d.; this dosage could be changed if necessary. The mean weekly number of days on which a stool was passed in the cisapride and placebo group increased to 5.3 and 4.4 (p less than 0.05) during weeks 8-12 of treatment, and the number of days with stools of normal consistency increased to 3.5 and 1.9 (p less than 0.05), respectively. At week 12, the reduction in severity and frequency scores for abdominal pain was significantly greater (p less than or equal to 0.05) in the cisapride group (60 and 61%) than in the placebo group (40 and 32%), as it was for abdominal distension (p less than 0.05). Cisapride tended to be better than placebo in diminishing flatulence. In 71% versus 39% of the patients the overall rating for the response to treatment was good or excellent at week 12. Cisapride was well tolerated. These results suggest that the drug will be useful for the management of constipation-predominant IBS.
Comparison of a new immunoassay for determining serum pancreatic isoamylase with two standard techniques. A method has recently been developed for measuring serum pancreatic (P) isoamylase, using two monoclonal antibodies specific for salivary isoamylase. We performed this test on 67 healthy controls and 133 patients: 15 with acute pancreatitis, 53 with chronic pancreatitis (20 during painful relapse and 33 in clinical remission), 18 with pancreatic cancer, 41 with nonpancreatic disease with abdominal pain, five with macroamylasemia, and one with total pancreatectomy. Results were compared with those of a wheat germ inhibition method and with electrophoresis on cellulose acetate. A close correlation was found between the results of immunoinhibition assay and those of the other two tests. All patients with acute pancreatitis had abnormally high values in all three tests. In the group with chronic pancreatitis studied during painful relapse, 16 had an increase in P-isoamylase, as determined with the immunoinhibition assay, 13 with the wheat germ inhibition test, and 15 with electrophoresis. In the group with chronic pancreatitis in clinical remission, we found low values in one patient, by immunoinhibition assay, but found low values in 17 and 19 patients by wheat germ inhibition and electrophoresis, respectively. Low P-isoamylase values corresponded to a severe exocrine pancreatic insufficiency. In the group with pancreatic cancer, the three tests showed similar results, and the majority of the patients had normal values. In the patients with nonpancreatic diseases, abnormally high levels were found in five, by immunoassay, in four by electrophoresis, and in three by the wheat germ inhibition method. In the five cases with macroamylasemia, both inhibition assays erroneously demonstrated an abnormal P-isoamylase elevation. The results show that the three tests are equally useful for the diagnosis of acute pancreatitis, or chronic pancreatitis during an acute relapse. In these diseases, the immunoinhibition test would be the preferred assay because it is simple and rapidly performed.
Hemoperitoneum as a result of coital injury without associated vaginal injury. Hemoperitoneum as a result of coital injury without associated vaginal injury is an extremely rare entity, and evidence by only five cases that have been reported in the medical literature to date. We report five additional cases encountered in two medical centers. Two of these were ruptured corpus luteum cysts, one was a laceration of the round ligament, another was a laceration of an ovary, and the fifth was rupture of a serous cystadenoma. This diagnosis should be considered in patients with hemoperitoneum after coitus.
Severe mitral insufficiency post-balloon valvuloplasty: the late changes found in a disrupted mitral valve. The case of a 45-yr-old woman who had balloon valvuloplasty for rheumatic mitral stenosis is presented. An anterior mitral leaflet tear occurred as a complication of the procedure. Both partial healing of the anterior mitral leaflet and gradual dilatation of the left atrium occurred which allowed the damaged valve to remain in situ for several months. Some of the late changes which occur after such a complicated valvuloplasty are illustrated here, as this patient eventually required surgery and valve excision for definitive repair.
Metastatic tumors of the umbilicus: a review 1830-1989. Umbilical metastases from known and unknown primary cancers are rare. The eponym "Sister Mary Joseph's nodule" has been used by generations of physicians. The first reports of this clinical sign were from Walshe in 1846. A review of the literature revealed 265 cases from then until 1989. Only 85 cases of umbilical metastasis from unknown primary tumors were found. This review should help us to focus on the common and uncommon primary sites in the diagnosis of patients with this finding. A single case report and the work-up for the hidden primary tumor are described.
Late recurrence of a hepatocellular carcinoma in a patient with incomplete Alagille syndrome. In this study, the case of a patient presenting a second hepatocellular carcinoma 13 years after resection of a first tumor of the same type is reported. In this case, etiological investigations remained negative, but an incomplete form of syndromatic Alagille syndrome with paucity of bile ducts in the nontumoral tissue was detected and associated with nodular regenerative hyperplasia and foci of dysplasia. Malignant transformation in Alagille syndrome seems to be extremely rare. The fact that such tumors evolve very slowly could be an argument for partial hepatectomy and, if necessary, liver transplantation.
Persistent trophoblast after conservative treatment of tubal pregnancy: prediction and detection. The incidence of persistent trophoblast and risk of second surgical intervention after conservative treatment of tubal pregnancy are substantial. The preoperative and postoperative hCG patterns in patients with tubal pregnancy were studied to see whether this information could predict and detect persistent trophoblast at an early stage. Ninety-eight women with tubal pregnancy underwent conservative surgical treatment by laparoscopy or laparotomy. Eight developed postoperative complications necessitating a second operation, and seven of them had both biochemical and histologic evidence of persistent trophoblastic activity. In seven of 31 patients with preoperative hCG above 3000 IU/L, a second operation was necessary, whereas in 67 with preoperative hCG levels below 3000 IU/L, only one such intervention was necessary. Eight of the 22 patients with hCG above 1000 IU/L on the second day after surgery and seven of 11 patients with hCG above 1000 IU/L on the seventh day after surgery later needed a second surgical procedure. In contrast, 86 of 87 women with hCG below 1000 IU/L on the seventh day after surgery had an uneventful convalescence. We conclude that pre- and postoperative hCG measurements can identify patients at risk of developing persistent trophoblast. Further, in patients with preoperative hCG titers below 3000 IU/L, we recommend conservative surgery followed by measurement of hCG 1 week postoperatively.
Comparison of epidurally administered sufentanil, morphine, and sufentanil-morphine combination for postoperative analgesia. Postoperative analgesia provided by epidurally administered sufentanil and/or morphine was evaluated in 45 patients recovering from major gynecologic surgery. At the first complaint of pain in the Postanesthesia Care Unit, patients received a single epidural bolus of 30 micrograms sufentanil (group A), 5 mg morphine (group B), or 30 micrograms sufentanil plus 3 mg morphine (group C) in a randomized blinded fashion. Analgesic efficacy was assessed throughout the 24-h study period with 10-cm visual analog scales. The need for additional postoperative analgesia (patient-controlled analgesia, 1 mg of morphine every 6 min as necessary) and the incidence of adverse effects were also assessed. Patients receiving sufentanil (groups A and C) had significantly faster onset of analgesia than did patients given morphine alone (group B, P less than 0.05). Group B subjects experienced the longest duration of analgesia (B vs A and C, P less than 0.05) and required significantly less patient-controlled analgesia (morphine) than patients in group A (P less than 0.05). No patient developed clinically significant respiratory depression or excessive sedation, and there were no intergroup differences in incidence of pruritus or nausea (P value not significant). The data indicate that a mixture of sufentanil and morphine provides either a more rapid onset of epidural analgesia or reduced patient-controlled analgesia narcotic requirement than respective doses of each agent administered alone.
Five-year results of coronary bypass grafting for patients older than 70 years: role of internal mammary artery. Despite numerous references to the superiority of the internal mammary artery (IMA) over the saphenous vein for myocardial revascularization, its role in the elderly is still in question. From January 1984 through December 1988, 1,081 patients older than 70 years (mean age, 74.9 years) underwent bypass grafting, 354 (33%) receiving left IMA grafts based on the surgeon's preference and 727 (67%) receiving vein grafts only. Selection bias resulted in a higher incidence of known risk factors (such as cardiomegaly, arrhythmias, left ventricular failure, wall motion abnormalities, and preoperative combined New York Heart Association/Canadian Cardiovascular Association functional class IV) in patients in whom the IMA was not used. However, unstable angina, acute myocardial infarction, left ventricular dysfunction, and left main disease were not contraindications for using IMA grafts. The operative mortality rate was significantly lower in IMA patients (2.8% versus 7.6%). The actuarial 5-year survival rate (standard error) was higher in patients with IMA grafts, 89% (3%) versus 78% (2%), and postoperative functional class improved to a greater extent in IMA patients (87% of patients were in classes I and II). Arrhythmias and myocardial infarction were significant causes of late death only in patients with vein grafts. When patients are older than 70 years, patient selection factors clearly play an important role in the differential results between patients in whom the IMA is used and patients in whom vein grafts are used. As in younger patients, excellent results can be achieved in the elderly.
Toxic shock syndrome after inguinal hernia repair. Report of a case with patient survival. A 40-year-old man developed fulminant multisystem failure several days after elective repair of an inguinal hernia. Toxic shock syndrome (TSS) was diagnosed. There was, however, no evidence of wound infection at the time of multisystem failure. Only later in his hospital course did the wound drain. Staphylococcus aureus was cultured from the wound and was the presumed etiologic agent in the patient's life-threatening illness. The patient recovered fully with supportive care, antibiotics, and surgical debridement of the inguinal hernia site. This case is discussed in the context of existing literature on the toxic shock syndrome. The site of infection is typically nonsuppurative, but the systemic manifestations are typically life threatening. The responsible organism is commonly believed to be a strain of S. aureus that expresses a toxin (TSS toxin-1) that effects multisystem failure, but which also diminishes the local inflammatory response and explains the benign appearance of the wound. Although this is a rare clinical entity, elective surgical procedures complicated by fatal TSS have been reported. Surgeons should understand this disease and the management necessary to avert mortality.
Dysphagia as a manifestation of occult hypoxemia. The role of oximetry during meal times. A 25-year-old woman with severe kyphoscoliosis reported a six-month history of increasing dysphagia to both liquids and solids. A barium swallow and esophageal motility studies showed no significant gastrointestinal abnormalities. Trials of antispasmodic agents were unsuccessful in relieving her symptoms. Pulmonary function tests showed a severe restrictive ventilatory defect (vital capacity = 0.67 L) with adequate oxygenation and alveolar ventilation as reflected by arterial blood gas testing during quiet wakefulness. However, continuous noninvasive oximetry demonstrated desaturation to 85 percent while eating. These transient episodes of desaturation were abolished by the administration of supplemental oxygen delivered by nasal prongs. Following the prescription of supplemental oxygen, dysphagia resolved immediately, with weight gain following over several weeks. We conclude that dysphagia may be a presenting feature of hypoxemia. This case report draws attention to the usefulness of continuous noninvasive monitoring of oxygenation and the clinical importance of at least some transient hypoxemic events.
Lidocaine potentiation of cocaine toxicity. STUDY HYPOTHESIS: The toxic effects of cocaine are enhanced in the presence of lidocaine. STUDY POPULATION: Male Sprague-Dawley rats weighing 200 to 300 g. METHODS: Animals received intraperitoneal injections of cocaine (10, 20, 35, or 50 mg/kg), lidocaine (30 or 40 mg/kg), or a combination of all doses of cocaine given simultaneously with 30 or 40 mg/kg lidocaine. The incidence and time to seizure and death were recorded in these groups and compared by chi 2 and analysis of variance analyses, respectively. RESULTS: At doses of 30 or 40 mg/kg, lidocaine does not induce seizures or death. The effect of simultaneous injection of both cocaine and lidocaine was to dramatically increase the incidence of both seizures and death over that of cocaine alone. The incidence of seizures in animals receiving 35 mg/kg cocaine alone was 10%; this increased to 50% and 80% with the addition of 30 and 40 mg/kg lidocaine, respectively (P less than or equal to .05; P less than or equal to .01). Death did not occur in animals receiving 35 mg/kg cocaine alone; the addition of 30 and 40 mg/kg lidocaine resulted in death in 30% and 60% of animals, respectively (P less than or equal to .01 each group). Similarly, in rats receiving 50 mg/kg cocaine, the incidence of death increased from 0% to 60% and 80% with 30 and 40 mg/kg lidocaine, respectively (P less than or equal to .01). CONCLUSION: In the rat, overall toxicity of cocaine is significantly increased with simultaneous exposure to lidocaine.
Increased whole blood viscosity combined with decreased erythrocyte fluidity in untreated patients with essential hypertension. Erythrocyte fluidity and other haemorheological variables were studied in 22 patients with essential hypertension and compared with age- and sex-matched healthy controls. Hypertensive patients displayed a significantly lower erythrocyte fluidity (P less than 0.001). Similarly, significantly elevated values for haematocrit, plasma and whole blood viscosity, as well as aggregation tendency were observed compared to controls. Although differing in these respects from controls, there were no obvious relationships between these rheological variables and either systolic or diastolic blood pressure. The significantly lower erythrocyte fluidity and other changes in haemorheological variables of red blood cells found in hypertensive patients may be explained by an enlarged metabolic pool of free calcium ions in these red blood cells. It is suggested that the molecular mechanisms underlying the evolution of essential hypertension are multifactorial rather than being based on a single molecular derangement. Primary events resulting in altered physicochemical properties of the red blood cells may work in concert in the development of essential hypertension, in addition to the increased availability of calcium ions and their potential role in smooth muscle contraction.
Chronic functional gastrointestinal symptoms in Holocaust survivors. In Nazi-occupied Europe (1939-1945), Jews were submitted to extreme mental and physical hardships (the Holocaust). This study was designed to investigate the impact of the severe protracted suffering on the development of chronic functional gastrointestinal symptoms. Thus, we studied 623 consecutive patients of Eastern European origin who had been admitted for nongastrointestinal complaints. They filled out detailed questionnaires, and were divided into the following two groups: A) Holocaust survivors [237 subjects who had been for at least 6 months in either German concentration/extermination camps (95 subjects), ghetto and/or underground movements (65 subjects), labor camps not directly supervised by Germans (79 subjects)], and B) a control group (384 subjects from the same demographic background, who had not been exposed to Nazi persecutions). The symptoms investigated were the following: abdominal pain, irregular bowel habits, diarrhea, constipation, abdominal distension, heartburn, flatulence, anorexia, nausea, vomiting, mucus in stool, tenesmus, and aerophagia. Patients were defined as having functional symptoms after these had been present for at least 5 yr and relevant organic disease had been excluded. The prevalence, duration of suffering, and frequency of appearance of most symptoms were significantly higher in the group of Holocaust survivors. This study supports the clinical observations that severe and protracted suffering contributes to the development of chronic functional gastrointestinal symptomatology.
Management of Peyronie disease by implantation of inflatable penile prosthesis. Sixty-seven patients with advanced Peyronie disease were treated by implantation of an inflatable penile prosthesis (IPP). Twenty-eight of the 67 patients had documented total erectile failure. The remaining 39 patients had significant penile curvature causing "mechanical impotence" due to inability to achieve adequate vaginal penetration and chose implantation of an inflatable penile prosthesis (in some cases, combined with a straightening procedure) rather than one of the standard penile straightening procedures. Currently, 63 of the 67 patients have functioning prosthetic devices; in 3 other patients the device was removed because of infection, and 1 patient was dissatisfied and had the device removed. For impotent patients with severe Peyronie disease for whom other medical or surgical treatment is neither desirable nor suitable, we recommend implantation of an inflatable penile prosthesis combined with a possible straightening procedure.
A simple method to improve the accuracy of non-invasive ultrasound in selecting TIA patients for cerebral angiography. A prospective study is reported of the ability of B mode ultrasound imaging and continuous wave Doppler flow studies to detect different degrees of stenosis of the extracranial internal carotid artery (ICA) in 186 arteries in 99 patients with transient ischaemic attacks (TIA) and minor ischaemic stroke. A simple mathematical equation has been developed which combines the image and flow data to provide a single predictor of the degree of angiographic stenosis which has advantages over either ultrasonic modality used alone. The sensitivity and specificity of the predictive model in the detection of stenosis greater than or equal to 25% was 73% and 98%, of stenosis greater than or equal to 50% was 90% and 93%, of stenosis greater than or equal to 75%, 65% and 99% and occlusion 100% and 94% respectively. The principal clinical value of ultrasound screening is to spare patients with "non-significant" stenosis the risk of unnecessary angiography. Thus a simple measure of the Duplex screening tests' performance is the proportion of all strokes occurring as a complication of angiography that are avoided by changing the investigation policy from "angiograms for all carotid TIA and minor ischaemic stroke patients" to "angiograms for all patients with abnormal ultrasound results". If Duplex scanning were used to select patients most likely to have a significant abnormality on angiography, depending on the degree of stenosis to be detected, 52-85% of angiographic strokes might be avoided. If the predictive equation were used 62-88% of angiographic strokes might be avoided.