Frequency of cardiac contusion in nonpenetrating chest injury.

Seventy-five patients with nonpenetrating chest injuries were evaluated with electrocardiography, cardiac enzyme determination, 2-dimensional echocardiography and radionuclide ventriculography to document the incidence of cardiac abnormalities. Although the electrocardiograms showed ST-T wave changes in 25 patients (33%), sensitivity (47%) and specificity (79%) for echocardiographic and radionuclide abnormalities were poor. Cardiac enzymes were abnormal in 10 patients (13%), sensitivity for echocardiographic or radionuclide abnormalities, or both, was 29% and specificity 90%. Wall motion abnormalities were detected in 11 patients (18%) by radionuclide studies and in 3 patients (6%) by echocardiography. A pericardial effusion was present in 5 patients (10%). Two patients (4%) died of noncardiac causes; neither had wall motion abnormalities. This study documents the favorable outcome of patients with blunt chest injuries and does not suggest that echocardiography or radionuclide studies should be performed routinely on such patients.

Comparison of nitroglycerin patches and nifedipine.

Fifteen patients with stable angina participated in a 12-week crossover study to evaluate the efficacy of nifedipine and nitroglycerin patches. There was an initial 2-week drug washout period followed by a 2-week control period when patients received no other antianginal treatment other than sublingual nitroglycerin for relief of angina episodes. At the end of the 2-week control period, exercise performance was assessed with treadmill exercise testing and measurement of oxygen consumption during the final third of the dosing interval. Myocardial perfusion was assessed using thallium scintigraphy with the injection of thallium at 85% of the maximum oxygen consumption. Patients were then randomized to nifedipine or nitroglycerin patches, and the dosage was titrated at weekly intervals according to symptomatic response. The final dose was received for at least 2 weeks. After 4 weeks, patients received the alternate medication. Maximal exercise testing and thallium scintigraphy were repeated after each drug period. Both nifedipine (mean dose, 70 mg/day) and nitroglycerin patches (mean dose, 16 cm/day) significantly reduced the frequency of angina and the consumption of sublingual nitroglycerin. Nifedipine decreased the reversible thallium defect score (49 +/- 29 vs. 28 +/- 26 U, p less than 0.01). Both drugs reduced electrocardiographic evidence of myocardial ischemia at submaximal exercise. Maximal oxygen consumption was not significantly increased by either drug when the test was done during the latter part of the dosing interval. The clinical implications of this study are that the dosage of nifedipine and nitrate patches, based on symptomatic criteria of angina frequency reduction, may not result in objective improvement in exercise performance.

Natural history of untreated inferior vena cava injury and assessment of venous access.

Conventional policy mandates exploration of retroperitoneal hematomas presumed to contain penetrating injuries of the inferior vena cava (IVC). In clinical practice this maneuver frequently results in torrential blood loss, suggesting the injury may be best managed without exploration and IVC suturing. The present study was undertaken to define the natural history of untreated IVC perforations, and to assess venous access with such injuries. Twelve adolescent Hampshire pigs (20-25 kg) underwent halothane anesthesia and laparotomy. The infrarenal IVC was isolated temporarily and a posterior cruciate incision, equivalent to 50% of the IVC circumference, made via anterior venotomy. Animals were resuscitated with Ringer's lactate. Technetium sulfur colloid was injected 20 min postlaparotomy closure via either a jugular or femoral venous cannula, and count activity measured over the IVC injury site using a mobile gamma camera. The procedure was repeated via the counterpart limb. Background from the first injection was subtracted, and count ratios integrated from 16 to 19 min postinjection. Extravasation following lower extremity infusion was not significantly different from that following central venous administration. One pig succumbed to cryptogenic peritonitis one wk postinjury. The remaining animals were killed at periods ranging from 3 to 12 wk. No animal had clinical evidence of delayed bleeding, pulmonary embolus, or other venous sequelae during the observation period. At autopsy all vena cavae were normal caliber without evidence or pseudoaneurysm of thrombosis. This swine study confirms the efficacy of lower extremity venous access with contained IVC injury, and suggests that isolated retroperitoneal IVC injuries may be treated nonoperatively in very selected patients.

The use of videotaped role playing in training and evaluating gerontological counseling and outreach skills.

PIP: Videotape role playing was used as a training and evaluation technique in a program designed to train professionals, paraprofessionals, and volunteers providing gerontological services. The Mental Health Outreach Program, (MHOP), a training course initiated at the University of Notre Dame, varied in length from 3-5 months and was conducted 3 times in South Bend, Indiana, and 5 times at various sites in New Mexico. The program employed situations in which trainees were asked to counsel an elderly client, in a role play setting where the older individual was portrayed by a trained "actor." This exercise was one of several training procedures. Other training procedures included classroom training, group discussions, and fieldwork supervision. This paper reports the results from MHOP training sessions conducted in Albuquerque, New Mexico, in 1982, following a review of role playing in training. 2 evaluators with graduate training in gerontological counseling scored the videotaped records of the role playing sessions and rated the performance of 39 trainees and 15 control subjects on each of 13 dimensions. Each subject's performance was scored on a 1-7 point scale for each dimension; 7 represented an ideal performance and a 1 indicated an inept performance. The results suggest that the role playing experience was an important component of training. Both the expert rater's judgements of the trainees' skills on the 13 dimensions and the trainees' self-assessment of their skills on the same dimensions indicated improvement by the end of training. Mean overall scores for pretest and posttest performance were 4.7 and 5.3 for the self ratings and 4.9 and 5.2 for the expert ratings. Based upon expert's ratings, trainees improved on all 13 dimensions; 4 of these dimensions -- nondefensiveness, flexibility, ability to deal with unpleasant feelings, and noncondescension -- showed significant improvement and 3 dimensions -- diagnosis and probing, empathy, and listening -- approached significance. In a followup survey of the trainees' reactions to the entire training program, 82% of whose who had participated in the role playing exercises indicated they were extremely or moderately useful. To assess the role playing technique as a training evaluation procedure, scores from the 13 role play dimensions were analyzed using a multiple analysis of variance procedure. Trainees failed to show significantly greater improvement than controls from pretest to posttest role playing sessions, but trainees showed more overall improvement than comparison subjects.^ieng

Early prediction of avascular necrosis of the femoral head following femoral neck fractures.

The treatment of acute fracture of the femoral neck remains an unsolved problem. Fifty-three patients are presented using 99mTc phosphate scintigraphy with quantitative computer interpretation to predict the viability of the femoral head following acute fracture. The accuracy of prediction was 92.5%; the scans were incorrect in four patients. Armed with a safe, simple diagnostic procedure and a greater than 90% accurate prognosis, a rational program of treatment can be prescribed for the individual patient.

Metronome pacing and age: the effect of irrelevant stimuli.

Community resident and institutionalized elderly were compared with young subjects in their ability to ignore task-irrelevant stimuli in a time estimation task. Production and reproduction estimates were compared under three metronome conditions: no metronome, 40 beats per minute (bpm), and 80 bpm. The no-metronome estimates of both old groups were significantly shorter and more accurate than those of the young subjects; estimates were more accurate with the reproduction than with the production method. A significant "metronome driving" effect was seen in the estimates of the two old groups, especially the institutionalized one. The results are consistent with an increase in perceptual noise with age and also suggest that the social conformity of older persons and their susceptibility to irrelevant stimuli can be represented as an increase in field dependence with age.

Renal uptake of 99mTc-sulfur colloid in congestive heart failure.

Renal uptake of 99mTc-sulfur colloid during liver and spleen imaging was observed in 4 patients; all had moderate to severe congestive heart failure. Four similar patients with this association have been reported. Although the exact mechanism of colloid uptake by the kidneys is not known, an association with congestive heart failure seems likely.