Computerized tomography scan interpretation of a bone expansion technique.

Bone expansion can be defined as the manipulation of bone to form a receptor site for an implant without the removal of any bone from the patient. The way this technique is used provides a number of advantages to patients. There is a marked decrease in the need to graft ridges, even those as narrow as 1 mm. This results in less surgical time for the surgeon and much less cost to the patient. It also allows for the significant improvement of atrophic arch morphology and interarch relationships for the restorative phases. Soft tissue revisions at the time of implant placement allow for the development of keratinized tissue surrounding the implant, thus saving the patient the morbidity and cost of another surgical procedure. Cortical bone is preserved by not raising the periosteum during the manipulation of bone.

The changing presentations of diabetic ketoacidosis during pregnancy.

The purpose of the present study was to examine the presentation and outcomes associated with diabetic ketoacidosis (DKA) in pregnancies complicated by diabetes. Eleven episodes (2%) of DKA were diagnosed during the 10-year study period. All patients were under close observation by the Diabetes-in-Pregnancy Service. Plasma glucose levels of less than 200 mg/dL were present in 4 of the 11 patients (36%), 10 (90%) of whom presented with nausea, vomiting, and decreased caloric intake. Two subsequently had fetal distress necessitating cesarean section. One fetal death occurred in a patient treated with subcutaneous insulin. Despite contemporary methods of diabetes care, near-normal plasma glucose levels are not enough to preclude diabetic ketoacidosis. Nausea, vomiting, and decreased caloric intake in an otherwise normal pregnant, diabetic woman requires evaluation to exclude ketosis.

Safety of long-term flecainide and propafenone in the management of patients with symptomatic paroxysmal atrial fibrillation: report from the Flecainide and Propafenone Italian Study Investigators.

To compare the relative safety of flecainide acetate to propafenone HCl during long-term treatment (12 months), we conducted a randomized, open-label, comparative, parallel, multicenter trial in 200 patients with paroxysmal atrial fibrillation (AF) and no history of heart disease. Initial daily doses were flecainide 200 mg (n = 97) or propafenone 450 mg (n = 103). Dose escalations up to a maximum of flecainide 300 mg/day or propafenone 900 mg/day were permitted after > or = 2 attacks of paroxysmal AF. Patients were assessed for safety and drug tolerance at designated intervals over the 12-month study unless discontinued for adverse experience or inadequate response. Ten patients on flecainide reported 14 cardiac adverse experiences; 4 discontinued the drug. Seven propafenone patients reported 8 cardiac adverse experiences; 5 discontinued the drug. Three proarrhythmic events occurred: 1 propafenone patient developed ventricular tachycardia and 2 flecainide patients experienced AF with a rapid ventricular response. An intention-to-treat analysis showed that the probability of safe and effective treatment after 12 months was 77% for flecainide-treated patients and 75% for the propafenone-treated patients. There was an acceptable risk-benefit profile in patients with paroxysmal AF and no evidence of clinically significant heart disease who were treated with flecainide or propafenone for 12 months. Further, there was no statistically significant difference in safety or efficacy between flecainide and propafenone in this study.

Safety of flecainide versus propafenone for the long-term management of symptomatic paroxysmal supraventricular tachyarrhythmias. Report from the Flecainide and Propafenone Italian Study (FAPIS) Group.

In order to compare the long-term safety of flecainide and propafenone, an open label, randomized, parallel group study was performed in 335 patients with paroxysmal atrial fibrillation (n = 200) or paroxysmal supraventricular tachycardia (n = 135), and no history of heart disease. Patients were treated with an initial daily dose of flecainide 100 mg (n = 72) or propafenone 450 mg (n = 63) for paroxysmal supraventricular tachycardia and flecainide 200 mg (n = 97) or propafenone 450 mg (n = 103) for paroxysmal atrial fibrillation. Dose escalations were permitted after > or = 2 attacks, up to a maximum of flecainide 300 mg or propafenone 900 mg.day-1.Follow-up duration was 12 months, or when patients stopped the treatment as a result of inadequate efficacy or adverse experiences. Twelve patients on flecainide reported 16 cardiac adverse experiences, of whom six discontinued the treatment. Seven propafenone patients had eight cardiac adverse experiences, of whom five discontinued the treatment. Serious proarrhythmic events were infrequent: one case of ventricular tachycardia on propafenone: two cases of atrial fibrillation with rapid ventricular response on flecainide, associated in one patient with pulmonary oedema. An intention-to-treat analysis showed that the probability of 12 months' safe and effective treatment of paroxysmal supraventricular tachycardia was 93% for flecainide and 86% for propafenone (P = 0.24), whereas in paroxysmal atrial fibrillation it was 77% for flecainide and 75% for propafenone (P = 0.72). In conclusion, flecainide and propafenone were safe in the long-term treatment of patients with paroxysmal supraventricular tachyarrhythmias and without evidence of clinically significant heart disease.

Ultrasonography in the detection of aneuploidy in the first trimester.

Ultrasonography has been used increasingly in the first trimester to identify fetal anomalies as early as possible in gestation. First trimester sonographic screening may detect a greater proportion of aneuploid fetuses than sonography performed later in pregnancy, and it may allow determination of potential markers for prediction of chromosomal anomalies.

Clinical equivalence of a novel non-chlorofluorocarbon-containing salbutamol sulfate metered-dose inhaler and a conventional chlorofluorocarbon inhaler in patients with asthma.

BACKGROUND: New formulations of non-chlorofluorocarbon-containing propellants for pressurized metered-dose inhaler delivery systems must be developed in response to the forthcoming ban on chlorofluorocarbon (CFC) production. OBJECTIVE: This study compared the bronchodilator effects of 100, 200, and 300 micrograms (base equivalent) of salbutamol in a novel CFC-free propellant system (Airomir in the 3M CFC-Free System; 3M Pharmaceuticals, St. Paul, Minn.; 108 micrograms of salbutamol sulfate or 90 micrograms of salbutamol base equivalent per inhalation) with that of 100 and 200 micrograms of salbutamol base in a conventional CFC propellant system (Ventolin, CFC-11/12; Allen and Hanburys, Division of Glaxo Inc., Research Triangle Park, N.C.; 90 micrograms of salbutamol base per inhalation) and placebo. METHODS: Twenty-six patients with chronic, stable asthma, who had a forced expiratory volume in 1 second (FEV1) between 50.0% and 75.0% of predicted normal value, entered this randomized, double-blind, double-dummy, 6-period, crossover study. FEV1 was measured before and at multiple time points (ranging from 10 to 480 minutes) after administration of one, two, and three inhalations of salbutamol/CFC-free (100, 200, and 300 micrograms); one and two inhalations of salbutamol/CFC (100 and 200 micrograms); and placebo. Safety parameters included adverse events, heart rate, blood pressure, physical examinations, electrocardiograms, and clinical laboratory tests. Parametric analysis of variance models appropriate for a 6-period crossover design were used, along with multiple comparisons according to Tukey's method. RESULTS: All active treatments produced significantly (p < 0.0001) greater bronchodilation than placebo. The bronchodilator effect, as measured by FEV1 (peak percent change, peak as a percent of predicted value, duration, and area under the curve) after two inhalations of salbutamol/CFC-free was clinically comprable to two inhalations of salbutamol/CFC, with no clinically meaningful differences in safety parameters between the two delivery systems or between different dose levels. CONCLUSION: These results suggest that salbutamol/CFC-free may offer a suitable alternative for salbutamol/CFC when the need arises to change from CFC-containing salbutamol products.

Fetal blood sampling in human immunodeficiency virus--seropositive women before elective midtrimester termination of pregnancy.

OBJECTIVES: To explore the diagnostic potential of fetal blood sampling in the prenatal diagnosis of intrauterine human immunodeficiency virus infection and to investigate the transplacental transfer of human immunodeficiency virus antibody and p24 antigen in the second trimester of pregnancy, we studied serum and amniotic fluid obtained from 13 seropositive women and their fetuses before elective termination of pregnancy. STUDY DESIGN: Enzyme-linked immunosorbent assay, Western blot antibody analyses, and p24 antigen assays were performed on all samples. RESULTS: Human immunodeficiency virus antibody was detected by enzyme-linked immunosorbent assay and Western blot analysis in aliquots of maternal serum, amniotic fluid, and fetal serum from all 13 pregnancies. Each mother-fetus pair had identical antibody banding patterns. In contrast, p24 antigen was found in the maternal serum and amniotic fluid samples from five of 13 women (38%) and in serum from only three of 13 fetuses (23%). CONCLUSIONS: We conclude that fetal blood sampling, if combined with sophisticated serologic analysis, may have the potential to provide the diagnosis of congenital infection with human immunodeficiency virus. The correlation of immunologic, virologic, and molecular biologic methods with subsequent infant outcome and risk of iatrogenic infection of the fetus remains to be determined.

Correlation of symptoms with occurrence of paroxysmal supraventricular tachycardia or atrial fibrillation: a transtelephonic monitoring study. The Flecainide Supraventricular Tachycardia Study Group.

The purpose of this study was to determine whether symptoms recorded at the time of transtelephonic ECG monitoring (TTEM) correlate with attacks of paroxysmal supraventricular tachycardia (PSVT) or paroxysmal atrial fibrillation (PAF). We studied 113 patients with these arrhythmias who made a total of 3319 TTEM calls during their participation in double-blind, placebo-controlled, crossover, multicenter trials of flecainide therapy. Among 49 patients with PSVT, 62.7% of symptomatic calls were associated with ECG-documented PSVT as compared with 6.8% of asymptomatic calls (p less than 0.001). Similarly, among 69 patients with PAF, 69% of symptomatic calls were associated with ECG-documented PAF compared with 10.6% of asymptomatic calls (p less than 0.001). Both in patients with PSVT and PAF, an attack of PSVT or PAF could be documented by ECG in more than 70% of the calls when patients complained of tachycardia, increased sweating, or dyspnea. The sensitivity of a symptomatic call was 91% for PSVT and 89% for PAF, and it was not influenced by flecainide therapy. However, flecainide therapy was associated with a decrease in the positive predictive value of symptomatic TTEM calls and an increase in false positive TTEM transmissions. We conclude that in patients with symptomatic PSVT or PAF, there is a temporal relationship between symptoms and the occurrence of ECG-documented attacks of PSVT or PAF. However, sole reliance should not be placed on the presence or absence of symptoms as a measure of drug failure or efficacy, and it is important to document the cardiac rhythm by TTEM at the time symptoms are recorded.

Congenital heart disease and fetal thoracoabdominal anomalies: associations in utero and the importance of cytogenetic analysis.

We examined the frequency with which congenital heart disease (CHD) and cytogenetic abnormalities were found associated with omphalocele, gastroschisis, duodenal atresia and posterior diaphragmatic hernias. We performed fetal echocardiograms on 80 patients with these diagnoses and found congenital heart disease in 13 of 37 with omphalocele (35%), 2 of 17 with gastroschisis (12%), 4 of 15 with duodenal atresia (27%), and 2 of 11 with posterior diaphragmatic hernia (18%). Karyotypes were obtained in 74 and were abnormal in 24 (32%). Although most fetuses with these extracardiac malformations and abnormal karyotypes had associated CHD, many did not. Normal karyotypes were found in 69% of fetuses with CHD and omphalocele, and 50% of fetuses with CHD and duodenal atresia. We conclude that CHD may be present in fetuses with extracardiac malformations whether or not the karyotype is normal and that the prenatal evaluation of fetuses with these lesions should include both karyotype and fetal echocardiography. Although karyotypes play an important role in prenatal diagnosis, they are not predictive of normal cardiac structure when normal in the abnormalities studied. Even when the karyotype is normal in the presence of these abnormalities, fetal echocardiography is indicated.

Transcervical endoscopic verification of congenital anomalies in the second trimester of pregnancy.

Transcervical endoscopy was used to confirm prenatally diagnosed anomalies before elective termination of pregnancy. A complete anatomic survey was accomplished in 10 (70%) of 14 cases studied. Information was added to the ultrasonographic diagnosis in two cases, which changed the diagnosis in one fetus.

Urinary calcium as an early marker for preeclampsia.

Women who develop preeclampsia during pregnancy excrete less calcium than healthy pregnant women. Whether this reduction in calcium excretion precedes or follows hypertension is unknown. We prospectively measured urinary calcium excretion in 103 consecutive nulliparous women at risk for preeclampsia and presenting for prenatal care before 24 weeks' gestation. Serial 24-hour urine specimens were obtained at 10-24 weeks, 25-32 weeks, and 33 weeks to term. After delivery, the charts were reviewed for the presence of preeclampsia and gestational hypertension. At the first collection, patients who later developed preeclampsia excreted less urinary calcium (169 +/- 30 mg/24 hours; mean +/- standard error of the mean) than those who remained normotensive (298 +/- 15 mg/24 hours) (P less than .05); this reduction persisted throughout gestation. Using a receiver operator curve, we calculated a predictive threshold calcium value for hypertension of 195 mg/24 hours. The difference in the incidence of preeclampsia between pregnant women with calcium excretion values at or below 195 mg/24 hours (87%, 95% confidence interval 52-98%) and those with values above that level (2%, confidence interval 0.3-8%) was highly significant (Fisher exact test, P less than .0001). The 95% lower limit of relative risk for preeclampsia in patients with a calcium excretion equal to or below 195 mg/24 hours in the first collection was 9.4. These observations suggest a pathophysiologic role for altered urinary calcium excretion in women with preeclampsia that may contribute to the early identification of patients at risk for this disease.

Diagnosis and significance of cystic hygroma in the first trimester.

Thirty cases of cervical cystic hygroma were diagnosed in the first trimester of pregnancy. Karyotype analysis was available in 29 (97 per cent). Fifteen (52 per cent) had a chromosomal abnormality. The ultrasound appearance was described as posterior cervical, lateral cervical, or cervical hygroma with hydrops. Of the 14 euploid embryos, six were electively aborted, two are undelivered, and six have been delivered as phenotypically normal infants. In cases in which the chromosomes were normal and the pregnancy continued, all lesions resolved by 18 weeks.

Transvaginal ultrasonographic detection of congenital anomalies in the first trimester.

Transvaginal ultrasonography enables detailed visualization of the first-trimester pregnancy. Thirty-three structural anomalies have been diagnosed in the first trimester of pregnancy during a 2-year study period. An understanding of normal embryonic development is essential before attempting diagnosis in this gestational period.

Recurrent adverse pregnancy outcome and antiphospholipid antibodies.

Antiphospholipid antibodies, which include lupus-like anticoagulant and anticardiolipin antibody, have been linked to a number of adverse pregnancy outcomes, although their exact pathogenic mechanisms remain poorly defined. The relative risk of complications such as intrauterine growth retardation, spontaneous abortions, and stillbirth in patients with antiphospholipid antibodies also remains undetermined. Heightened attention has been focused on the association, leading to investigations into the pathogenesis. Uncontrolled studies have also explored therapeutic regimens such as aspirin, steroids, and heparin, and clinical trials have used various treatment protocols. Although knowledge into the association of antiphospholipid antibodies and recurrent adverse pregnancy outcome is limited and continues to evolve, this association provides new insights into the disease and offers promise for pharmacologic prophylaxis. In this article, current concepts on pathogenesis, diagnosis, and therapy are reviewed and recommendations are made for clinical care of these patients.

Invasive fetal assessment in the antepartum period.

Access to the fetus as a true patient is a recent development in maternal-fetal medicine. We review the major invasive techniques currently available for establishing diagnoses and providing treatments to the fetus. These include fetoscopy, fetal blood sampling, fetal transfusions, and fetal shunts. Indications, techniques, and complications are discussed.

Prenatal diagnosis of anterior parietal encephalocele with transvaginal sonography.

Transvaginal sonography identified an anterior parietal encephalocele that was not well-delineated by abdominal scanning. High resolution with access to the fetal head makes this modality ideal for studying the intracranial anatomy.

Embryoscopy: description and utility of a new technique.

Embryoscopy is a new technique for direct visualization of the first-trimester conceptus. A rigid fiberoptic endoscope is passed transcervically under ultrasonographic guidance into the chorionic cavity. Anatomic scrutiny and direct access to the developing embryo are made possible by this technique.

A comparison of transvaginal and abdominal ultrasound in visualizing the first trimester conceptus.

Ultrasound visualization of the first trimester embryo was compared using abdominal and transvaginal sonography. The parameters evaluated included the ability to obtain biometry, the ability to visualize detailed internal anatomy, and a subjective assessment of the overall image clarity. In 120 patients studied, transvaginal sonography was superior to abdominal sonography in obtaining biometric measurements in 51 cases (43%) and for visualizing internal anatomy in 45 cases (38%); also the image clarity of transvaginal sonography was subjectively better in 75 cases (63%). Vaginal sonography was superior to abdominal sonography in gestations less than or equal to 10 weeks, in obese patients, and in patients with retroverted uteri. The major difficulty encountered with transvaginal sonography was the limited maneuverability of the probe to generate specific views. Vaginal sonography can be a valuable tool in imaging the first trimester fetus, complementing, not replacing, abdominal sonography.

In utero intravesicular pressure and the prune belly syndrome.

The pathogenesis of the prune belly syndrome is unclear. The proposed etiologies include a distal obstructive uropathy or a mesodermal defect of the anterior abdominal wall and urinary tract. Detection of increased intravesicular pressure might identify those fetuses with an obstructive etiology who, therefore, would benefit from shunting.