123rc/medical_text huggingface dataset:
Acute appendicitis in the pregnant patient. Acute appendicitis is the most common surgical problem in pregnancy requiring emergent intervention. To establish a contemporary patient profile and formulate an effective management strategy, a retrospective review was conducted of 84 pregnant patients who underwent laparotomy with a preoperative diagnosis of acute appendicitis. Gestational stage at presentation included the first trimester in 27 patients (32%), the second trimester in 37 patients (44%), the third trimester in 13 patients (16%), and the puerperium in 7 patients (8%). Fifty-four patients (64%) had pathologically proven acute appendicitis; the incidence did not vary by trimester. Other intra-abdominal conditions were detected in 15 patients (18%). There were no significant differences between patients with positive and negative laparotomies (or among trimesters) regarding frequency of presenting symptoms and signs or laboratory results. Operation occurred within 24 hours of symptom onset in 19 of 54 (35%) instances of proven acute appendicitis. Perforation occurred in 23 of 54 patients (43%), all of whom had symptoms exceeding 24 hours (p less than 0.0005). Five instances of perinatal death and one case of extreme perinatal morbidity were associated with negative laparotomies; only one of these was attributed to operation itself. No adverse long-term maternal morbidity or mortality occurred. Wound infection developed in seven cases of acute appendicitis (six perforated) and two negative explorations. We conclude that (1) gestational physiologic changes obscure the accurate diagnosis of acute appendicitis; (2) the natural history of acute appendicitis is not affected by trimester of presentation; and (3) adverse sequelae of acute appendicitis are obviated by prompt operative exploration and prevention of appendiceal perforation.
Normal and diffusely abnormal myocardium in humans: functional and metabolic characterization with P-31 MR spectroscopy and cine MR imaging. The current study tested the concept that cine magnetic resonance (MR) imaging and phosphorus-31 MR spectroscopy might be used to provide a comprehensive evaluation of the functional and metabolic status of the myocardium in humans. Thirteen patients with congestive cardiomyopathy and eight healthy volunteers were imaged at 1.5 T with the one-dimensional chemical shift imaging technique for localization of P-31 MR spectroscopy and an electrocardiographically referenced gradient refocused sequence for imaging of the heart. Prominent peaks in the PDE and PME regions were observed in cardiomyopathic patients, but only the former peak was measured. The PCr/beta-ATP peak ratio was not significantly lower in cardiomyopathic patients compared with healthy subjects (1.51 +/- 0.08 vs 1.54 +/- 0.04). The ratios of PDE/PCr (0.80 +/- 0.07 vs 0.54 +/- 0.10) (P less than or equal to .01) and PDE/beta-ATP (1.19 +/- 0.10 vs 0.84 +/- 0.08) (P less than or equal to .05) were significantly higher in patients with dilated cardiomyopathy compared with healthy volunteers. Left ventricular systolic wall thickening was significantly lower and left ventricular peak and end-systolic wall stress and mass were significantly higher in cardiomyopathic patients compared with healthy volunteers. Thus, localized, gated P-31 MR spectroscopy combined with cine MR imaging allowed identification of both abnormal myocardial phosphate metabolism and abnormal ventricular function. While this study suggests that increased myocardial PDEs may be a marker for abnormal myocardium, the sensitivity and specificity of this marker need to be further evaluated.
Prehospital cardiac arrest: the impact of witnessed collapse and bystander CPR in a metropolitan EMS system with short response times. OBJECTIVE: Numerous studies have shown initiation of bystander CPR to significantly improve survival from prehospital cardiac arrest. However, in emergency medical services (EMS) systems with very short response times, bystander CPR has not been shown to impact outcome. The purpose of this study was to determine the effect of bystander CPR on survival from out-of-hospital cardiac arrest in such a system. DESIGN: Prehospital, hospital, and death certificate data from a medium-sized metropolitan area were retrospectively analyzed for adult, nontraumatic cardiac arrest during a 16-month period. RESULTS: A total of 298 patients met study criteria. One hundred ninety-five arrests (65.4%) were witnessed, and 103 (34.6%) were unwitnessed. Twenty-five witnessed victims (12.8%) were discharged alive, whereas no unwitnessed victims survived (P less than .001). Patients suffering a witnessed episode of ventricular fibrillation/tachycardia (VF/VT) were more likely to survive (21.9%) than were other patients (2.0%, P less than .0001). Among witnessed patients, initiation of bystander CPR was associated with a significant improvement in survival (20.0%) compared with the no-bystander CPR group (9.2%, P less than .05). Bystander CPR was also associated with improved outcome when witnessed patients with successful prehospital resuscitation were evaluated as a group; 18 had bystander CPR, of whom 13 (72.2%) survived compared with only 12 of 38 patients with no bystander CPR (31.6%, P less than .01). CONCLUSION: Our data revealed improved survival rates when bystander CPR was initiated on victims of witnessed cardiac arrest in an EMS system with short response times.
Cystic adenoma of the pigmented ciliary epithelium. Clinical, pathologic, and immunohistopathologic findings. A 51-year-old white man was found to have a deeply pigmented mass in the ciliary body and peripheral choroid of his right eye with an associated vitreous hemorrhage. Although the tumor appeared to be a ciliochoroidal melanoma, a melanocytoma and adenoma of the pigment epithelium also were considered in the differential diagnosis. The tumor was removed by a large partial lamellar sclerocyclochoroidectomy. Results of histopathologic evaluation showed a cystic adenoma of the pigmented ciliary epithelium. To the authors' knowledge, this was the first immunohistopathologic study of this tumor. Results of the study showed marked immunoreactivity for low molecular weight cytokeratins, vimentin, and S-100 protein. These immunohistochemical studies are consistent with the origin of this tumor from pigment epithelial cells.
Giant hemangioma of the liver with pain, fever, and abnormal liver tests. Report of two cases. In conclusion, we report the cases of two patients with large hemangiomas of the liver, abdominal pain, increased ESR and fibrinogen, increased serum alkaline phosphatase and gamma-glutamyltransferase activity, and normal white blood cell counts. Clinical and biochemical abnormalities disappeared after surgical resection. Increased ESR and fibrinogen are probably related to thrombosis within the tumor. This mode of presentation may suggest a diagnosis of hepatocellular carcinoma.
Bone cancer incidence rates in New York State: time trends and fluoridated drinking water. BACKGROUND: Recent animal studies of the potential carcinogenicity of fluoride prompted an examination of bone cancer incidence rates. METHODS: Trends in the incidence of primary bone cancers, including the incidence of osteosarcomas were examined among residents of New York State, exclusive of New York City. Average annual osteosarcoma incidence rates in fluoridated and non-fluoridated areas were also compared. RESULTS: Among persons less than 30 years of age at diagnosis, bone cancer incidence among males demonstrated a significant increase since 1955, while incidence among females has remained unchanged. A significant decrease in bone cancer incidence rates since 1955 was observed among both males and females age 30 years and over at time of diagnosis. Osteosarcoma incidence rates have remained essentially unchanged since 1970, among both younger and older males and females. The average annual age adjusted incidence of osteosarcomas (1976-1987) in areas served by fluoridated water supplies was not found to differ from osteosarcoma incidence rates in non-fluoridated areas. CONCLUSIONS: These data do not support an association between fluoride in drinking water and the occurrence of cancer of the bone.
Diagnosis of recent myocardial infarction with quantitative backscatter imaging: preliminary studies. Acute myocardial ischemia and chronic myocardial infarction may be recognized with ultrasound tissue characterization techniques because of myocardial acoustic changes caused by reduced perfusion and/or collagen deposition. Our purpose was to study the acoustic properties of recent myocardial infarction when the predominating pathologic finding was myocardial edema and leukocytic infiltration. We used a new quantitative backscatter imaging system to study 18 patients 9 +/- 5 days after myocardial infarction (eight patients with anteroseptal myocardial infarction and 10 with inferior myocardial infarction) and 20 normal subjects. The cyclic variation of relative integrated backscatter (end-diastolic minus end-systolic) was calculated from on-line measurements. Standard parasternal long- and short-axis and apical four- and two-chamber views were obtained. In the anteroseptal myocardial infarction group, the cyclic variation of relative integrated backscatter was lower in the septum (1.5 +/- 1.6 dB) than in the posteroinferior wall (3.2 +/- 1.2 dB); however, the sample size of only three patients (of eight patients imaged) in the latter group prevented statistical comparison. The cyclic variation of relative integrated backscatter in the infarcted septum was less than the measurement obtained in the septum of the control group (4.3 +/- 2.4 dB, p less than 0.05). In the inferior infarction group, the cyclic variation of integrated backscatter in the posteroinferior wall (1.8 +/- 1.7 dB) was not significantly different from the measurement obtained in the septum (3.7 +/- 3.6 dB); however, the cyclic variation in the posteroinferior wall was significantly less than that obtained in the control group posteroinferior wall (5.7 +/- 1.7 dB, p less than 0.05).
Orbit, skull base, and pharynx: contrast-enhanced fat suppression MR imaging. The high signal intensity of fat on T1-weighted magnetic resonance images has limited the utility of gadopentetate dimeglumine in imaging of the extracranial head and neck. Enhancing lesions may be obscured either by proximity to fat or by chemical misregistration artifact. The authors evaluated the role of a gadolinium-enhanced fat suppression imaging technique in the detection of extracranial head and neck abnormalities in 29 patients. These studies were directly compared with conventional pre- and postcontrast T1- and T2-weighted SE sequences. In detecting and defining the extent of abnormalities, fat-suppressed images were superior to non-fat-suppressed gadolinium-enhanced T1-weighted images in the majority of cases (22 of 27 [81%]). Fat-suppressed images were particularly beneficial in the detection of perineural spread of tumor as well as in defining lesions situated within or adjacent to fat-containing areas such as the base of the skull. These findings demonstrate that fat suppression techniques in combination with gadolinium enhancement are of value in extracranial head and neck imaging and should replace conventional postcontrast T1-weighted SE imaging.
Emergency department diagnosis of ectopic pregnancy. STUDY OBJECTIVES: To assess the accuracy of the history and physical examination as compared to the addition of serum progesterone screening for ectopic pregnancy in women presenting to the emergency department. DESIGN: Prospective, consecutive case series, N = 2,157. SETTING: ED of the Regional Medical Center at Memphis, a publicly subsidized, 450-bed acute care hospital staffed by residents and faculty of the University of Tennessee, Memphis. TYPE OF PARTICIPANTS: All ED patients with a positive urine pregnancy test treated between January 1 and December 31, 1988. INTERVENTIONS: Screening history, physical examination, and serum progesterone (P) and quantitative human chorionic gonadotropin (hCG) titer. MEASUREMENTS: All discharged patients were given follow-up appointments within two weeks; those found to have a P less than 25 ng/mL were called to return for repeat hCG and transvaginal ultrasound. MAIN RESULTS: One hundred sixty-one of 2,157 patients (7.5%) with a positive urine pregnancy test were found to have an ectopic pregnancy. All but five had a P of less than 25 ng/mL (sensitivity, 97%); four of these were admitted for immediate surgery because of symptoms. Overall, the ED physician detected 89 of 161 ectopics (55.3%) on initial presentation, 53 (60%) of which were ruptured at the time of surgery. Seventy-two patients (44.7%) who were discharged but later found to have an ectopic pregnancy had benign clinical presentations, including 41 with vaginal bleeding. There were no statistically significant differences in the presenting symptoms of patients with unruptured ectopics compared with normal intrauterine pregnancies. All but one of the 72 discharged patients were noted the following day to have a progesterone of less than 25 ng/mL and contacted to return. Eight of these were found to have a ruptured ectopic at the time of surgery. Only 91 of 161 patients (56.5%) with ectopic pregnancy acknowledged one or more clinical risk factors on follow-up questioning. CONCLUSION: The standard history and physical examination, including those performed by gynecologic specialists, are insufficiently sensitive for early detection of unruptured ectopic pregnancy. EDs with a high incidence of ectopic pregnancy should strongly consider implementation of a universal progesterone screening program to decrease unnecessary patient morbidity and the risk of mortality from undiagnosed ectopic pregnancy.
Survival with regional and distant metastases from cutaneous malignant melanoma. The clinical course of 312 consecutive patients after initial presentation with metastatic melanoma, 165 of whom presented with regional metastases at cutaneous or subcutaneous, or both, nodal sites and 147 with metastases at distant sites, was reviewed. The five year survival rate for regional metastases was 43.4 per cent compared with a five year survival rate for distant metastases of 4.9 per cent (p less than 0.0001). Favorable prognostic variables for survival from first regional metastases included primary melanoma sites on the extremities compared with the head, neck and trunk (p = 0.043) and a disease-free interval of more than one year from primary surgical treatment to regional metastases (p = 0.0058). Favorable prognostic variables for survival from the first distant metastasis included a disease-free interval of more than one year from primary surgical treatment to distant metastases (p = 0.0092), the type of resection of metastatic disease (p = 0.00027) and the addition of systemic immunotherapy (p = 0.0011). Forty-nine patients with totally resectable distant metastases had a five year survival rate from the treatment of the initial metastasis of 13.1 per cent, whereas 33 patients having palliative resections had a five year survival rate of 7.5 per cent. All 165 patients who did not have resection for distant metastases died within five years. The results of our experience support therapeutic efforts to ablate both regional and distant metastases of malignant melanoma when feasible.
Low-dose heparinization can be used with DEAE-cellulose hemodialysis membranes. The ability of DEAE-cellulose (Hemophan) membranes to bind heparin may reduce bioavailable heparin and predispose to dialyzer clotting, thus preventing use of Hemophan with low-dose heparin. To examine this possibility, residual blood volumes were determined following 95 treatments with dialyzers containing Hemophan membranes in 11 patients. No heparin was added to the saline used to prime the dialyzers. The anticoagulant effect of heparin was measured using recalcified activated clotting times (RACT). Two heparin doses, calculated by a pharmacokinetic model to increase baseline RACT by 12.5% and 25%, were used for each patient. The mean heparin loading doses were 10.2 +/- 2.8 and 15.3 +/- 2.2 IU/kg, respectively, and the mean infusion rates were 11.1 +/- 3.2 and 14.7 +/- 3.2 IU/kg/h, respectively. Residual blood volumes were determined by red cell lysis and hemoglobinometry. In 88 treatments, residual blood volume averaged 1.6 +/- 1.5 ml. In the other seven treatments, residual blood volume greater than 10 ml was seen. In five of these cases, clotting appeared to propagate from the arterial drip chamber. Residual blood volume did not correlate with the level of heparin. The data show that low-dose heparin can be used with Hemophan membranes, and suggest that blood tubing design may be an important factor in blood circuit clotting during hemodialysis.
Upper-airway obstruction after multilevel cervical corpectomy for myelopathy. We reviewed the cases of seven patients who had had obstruction of the upper airway immediately after an anterior procedure on the cervical spine and had required reintubation. All patients had had moderate or severe myelopathy preoperatively (average, 3.6 on the Nurick scale), and all had had a multilevel anterior cervical corpectomy for decompression followed by arthrodesis. The early compromise of the upper airway was believed to be due to edema rather than to the formation of a hematoma. Five patients had no sequelae, but two died of complications related to the obstruction. Risk factors common to these patients included moderate or severe myelopathy and multilevel corpectomy. Six patients had a history of heavy smoking and one, of asthma. We believe that extra caution should be used in the postoperative management of the airways when multilevel corpectomy is performed in patients who have these pre-existing conditions.
Airway hyperresponsiveness in patients with microvascular angina. Evidence for a diffuse disorder of smooth muscle responsiveness. Anginal chest pain in patients with angiographically normal coronary arteries may be caused by a limited coronary flow response to stress because of abnormal function of the coronary microcirculation (microvascular angina). Studies of forearm arterial function suggested that patients with microvascular angina may have a diffuse disorder of smooth muscle tone. Because dyspnea is common in these patients and seems disproportionate to the severity of myocardial ischemia, we studied air flow (forced expiratory volume in 1 second, or FEV1) in the basal state and after methacholine inhalation to determine whether bronchial smooth muscle is affected in this syndrome. Five of 36 patients with microvascular angina had a basal FEV1 of less than 70% of that predicted and did not receive methacholine. Of the remaining 31 patients, 14 (45%) had a more-than-20% reduction in FEV1 after methacholine inhalation (as much as 25 mg/ml), a response significantly greater than that of nine patients with heart disease (0%, p less than 0.025) and 24 normal volunteers of similar age and gender distribution (13%, p less than 0.025). Furthermore, the product of the methacholine dose inhaled and the magnitude of decline in FEV1 from baseline (methacholine response score) was significantly lower in patients with microvascular angina than in normal volunteers (16 +/- 8.6 versus 22.2 +/- 3.7, p = 0.026). We conclude that airway hyperresponsiveness is frequently demonstrable in patients with microvascular angina; these findings are consistent with our hypothesis that this syndrome may represent a more generalized abnormality of vascular and nonvascular smooth muscle function.
Experimental pericardial effusion: relation of abnormal respiratory variation in mitral flow velocity to hemodynamics and diastolic right heart collapse Pericardial effusion is associated with an abnormal increase in respiratory variation in mitral flow velocity. However, the relation of the changes in flow velocity to pericardial pressure, hemodynamics and two-dimensional echocardiographic findings is not established. Therefore, 11 sedated dogs with extensive hemodynamic instrumentation were studied with two-dimensional and Doppler echocardiography during four stages of progressively larger pericardial effusion. During all stages of effusion, respiratory variation in peak mitral flow velocity in early diastole and left ventricular isovolumetric relaxation time was increased compared with baseline (p less than 0.05). This increase was seen at the earliest stage of effusion (mean pericardial pressure 4.2 +/- 1.4 versus -0.8 +/- 0.9 mm Hg at baseline, p less than 0.05), and preceded the appearance of unequivocal diastolic right heart collapse in every dog. Maximal respiratory variation coincided with the appearance of right atrial collapse (mean pericardial pressure 7.1 +/- 2.4 mm Hg; mean inspiratory decrease in aortic pressure 9.5 +/- 2.6 mm Hg; mean aortic pressure 88.2 +/- 15.2 versus 102.2 +/- 11.2 mm Hg at baseline, p less than 0.05; and cardiac output 3.8 +/- 1.2 versus 5.5 +/- 1.3 liters/min at baseline, p less than 0.05), but did not increase at stages associated with more severe hemodynamic compromise. In addition, the respiratory changes in peak mitral flow velocity in early diastole were associated with simultaneous changes in the diastolic transmitral pressure gradient. It is concluded that in this model of acute pericardial effusion 1) increased respiratory variation in early diastolic mitral flow velocity, peak mitral flow velocity in early diastole and left ventricular isovolumetric relaxation time occurs almost immediately as pericardial pressure increases and persists at all stages of increasing pericardial effusion; 2) the abnormal respiratory variation occurs before equalization of intracardiac pressures and before the onset of unequivocal right heart collapse; 3) the respiratory variation occurs as a result of changes in the diastolic transmitral pressure gradient; and 4) the magnitude of the respiratory change is not necessarily predictive of pericardial pressure or severity of hemodynamic compromise, especially at the more severe stages of pericardial effusion.
Metastatic small cell tumor of bone with 'true' rosettes and glial fibrillary acidic protein positivity. A 15-year-old black girl was admitted to St. Jude Children's Research Hospital with a lytic lesion involving the right fourth metacarpal bone with a solitary metastasis to the ipsilateral axillary lymph node. Histologic examination of both the primary lesion and metastasis revealed a primitive small round cell lesion. Abundant rosettes with central lumina were present in the metastasis. Immunohistochemical stains performed on sections of the metastasis were strongly positive for glial fibrillary acidic protein (GFAP) and negative for neuron-specific enolase (NSE), S-100 protein, and Leu-7. Electron microscopic examination of the metastasis revealed lumen formation with apical microvilli and juxtaluminal junctional complexes. This tumor exhibits features that are suggestive, but not definitive, of primitive ependymal differentiation and further expands the morphologic and immunophenotypic range of small round cell tumors of bone.
The effects of rate, sequencing, and memory on auditory processing in the elderly. Auditory sequencing, rate, and memory were evaluated in three age groups with a series of subtests that require the identification of tones (Repetition Test; Tallal & Piercy, 1973). The older elderly group (M age = 80), but not the younger elderly group (M age = 70), performed significantly (p less than .05) poorer than the young adult group (M age = 25) when auditory memory of 4 and 5 tones was required and when the interstimulus interval was decreased. Performance was not related to hearing sensitivity, thus suggesting that changes in the auditory mechanism that occur with age may encompass more than a loss of hearing sensitivity. Moreover, performance on the Repetition Test did correlate with memory for digits, which indicates a relationship between auditory processing and higher cortical functions.