A comparison of outcome criteria in the diagnosis of renovascular hypertension.

The outcome criteria used for the diagnosis of renovascular hypertension (RVHT) following renal revascularization have not been validated. Differing criteria of indeterminate accuracy have yielded conflicting conclusions concerning the prevalence and efficacy of treatment of RVHT. We compared the accuracy of conventional outcome criteria used in the diagnosis of RVHT to that of novel, ordered outcome analysis to determine whether such an analysis might provide a more consistent means of diagnosing RVHT. Twenty-seven patients underwent intervention for treatment of presumed RVHT (group I), and 40 patients with presumed essential hypertension were treated with antihypertensive medication alone (group II). A standard dichotomized (improved or unimproved) outcome scheme and a five-level, ordered outcome scheme (ranging from definitely unimproved to definitely improved) were used to generate nominal outcomes of therapy for each patient. The resultant outcome groups were examined to determine the effect of such partitioning on blood pressure and medication requirements. To determine their diagnostic accuracy, the conventional and ordered outcome schemes were compared with a consensus outcome scheme derived from the use of numerous criteria. Significant correlations were observed between the ordered outcome score and posttreatment reductions in systolic blood pressure (r = 0.53, p = 0.007), diastolic blood pressure (r = 0.74, p = 0.0001), and medication score (r = 0.71, p = 0.0001). Overall diagnostic accuracy was estimated to be 91% for ordered criteria and 85% for dichotomized criteria. Correlation of the ordered and conventional schemes' assignments with the consensus scheme's assignments was 0.79 (p = 0.0001) and 0.63 (p = 0.0001), respectively. A simple, ordered outcome scheme compares favorably with the standard dichotomized scheme in assigning a diagnosis of RVHT to patients following renal revascularization or nephrectomy. The ordered scheme offers the advantages of simplicity and accuracy over current schemes.

Routine 36-week hemoglobin and hematocrits: are they necessary?

Different schedules for hemoglobin and hematocrit (H&H) screening of pregnant women exist at various hospitals in the Air Force. Charts of women delivering between November 1990 through February 1991 were reviewed for 28-week, 36-week, and labor admission H&H; 111 were included in the study. Statistical analysis of the data obtained showed that 28-week values were significantly lower (p > 0.01) than the 36-week values, which were lower (p > 0.01) than those on admission. This study indicates that screening at 36 weeks does not improve prenatal care and increases both discomfort for the patient and the workload for the laboratory.

Endocervical cell recovery.

Three thousand six hundred fourteen Papanicolaou smear reports were evaluated for endocervical cells and characteristics of the patients at the time the slide was taken. Differences were found related to the age of the patient, pregnancy/postpartum status, and cytology. The use of hormones when the smear was taken did not appear to affect the presence of endocervical cells. Many clinicians, believing that not obtaining endocervical cells results from failure to sample the endocervical canal, repeat those smears. This study is consistent with previous ones in finding that other factors, including patient characteristics, have a definite effect on the results. Repeating smears solely for lack of endocervical cells does not appear to be warranted for either the patient or the provider.

Reduction of myocardial infarction after emergency coronary artery bypass grafting for failed coronary angioplasty with use of a normothermic reperfusion cardioplegia protocol.

Emergency coronary artery bypass grafting is necessary in 2.7% to 13.5% of patients undergoing elective percutaneous transluminal coronary angioplasty. Myocardial infarction develops in 11% to 49% of these patients, with 18% to 46% of infarcts resulting in new Q waves. Since February 1987 a revised protocol for myocardial preservation has been used in 19 patients undergoing emergency bypass grafting for failed angioplasty. Cardioplegia is induced with a normothermic blood cardioplegic solution. Multiple maintenance doses of cold (4 degrees C) blood cardioplegic solution are then delivered through the aortic root and vein grafts. Before the aortic crossclamp is removed, normothermic reperfusion cardioplegic solution is delivered through the aortic root and vein grafts. This group was compared with all patients undergoing emergency bypass grafting for failed angioplasty before February 1987. These 45 patients received cold induction of cardioplegic solution, multiple maintenance doses of cold cardioplegic solution, and no reperfusion cardioplegic solution. The prevalence of myocardial infarction in the group receiving cold cardioplegic solution was 65% versus 26% in the group receiving normothermic cardioplegic solution (p less than 0.007). Multivariate analysis identified the use of the normothermic cardioplegia protocol (p less than 0.005), nontotal occlusion of the angioplasty vessel (p less than 0.03), and presence of collateral flow to the angioplasty vessel (p less than 0.04) as being independently associated with absence of myocardial infarction.

Minimal resection for bronchogenic carcinoma. An update.

Minimal resection with curative intent was performed for 24 patients with stage I bronchogenic carcinoma at our institutions over a 12-year period. This was usually done for patients who could not tolerate more extensive resections. The five-year actuarial survival rate was 65 percent. The rate of local recurrences was 13 percent (3/24), and the rate of distant recurrences was 17 percent (4/24), with a median follow-up of 38 months. Survival and recurrence rates are similar for patients undergoing minimal resection and those being reported for patients undergoing more extensive resections for stage I bronchogenic carcinoma. In selected patients, minimal resection should be considered as an acceptable alternative treatment for patients with stage I bronchogenic carcinoma.

Stripping the fetal membranes at term. Is the procedure safe and efficacious?

A prospective, randomized investigation was undertaken in a low-risk group of pregnant women at term (38-42 weeks' gestation) to determine if stripping the fetal membranes would safely result in earlier delivery. Ninety-nine patients entered the study; 51 underwent stripping of the membranes, and 48 controls did not. Fifty-nine percent of the patients in the stripped group delivered within one week as compared to 21% in the nonstripped group (P less than .0003). Two pregnancies in the stripped group advanced beyond 42 weeks' gestation as compared to six pregnancies in the control group (P = .12). A single gravida in the control group developed chorioamnionitis during labor. There were no other infections or other complications. Stripping the membranes was associated with earlier delivery and was not associated with any complications.

Prevalence of dental caries in USAF family members age 3-15.

This study was undertaken to determine the caries prevalence and restorative needs of United States Air Force (USAF) family members ages 3-15. Examinations were performed on 1802 USAF children at five bases. Indexes recorded were: Decayed, Missing, Filled Surfaces (DMFS) for permanent teeth; decayed, filled surfaces (dfs) for primary teeth; and a Dental Restorative Treatment Need Index. Results indicate an increase in the dfs and DMFS index with age, with more caries present in young children located overseas. No significant differences between children of officers and enlisted members were found. A higher dfs and DMFS index was found in other racial families as compared to blacks or whites. This study's overall population sample had a higher dfs index but lower DMFS index than the 1986-87 NIDR survey showed.

The effect of air abrasive polishing on blood pH and electrolyte concentrations in healthy mongrel dogs.

The recent re-emergence of air abrasive polishing as an adjunct to professional tooth cleaning has been accompanied by a substantial amount of research. Most of this research has focused on the efficacy of the Prophy-Jet and similar devices in the removal of plaque and stain and on the effects of such devices on restorative materials and the various hard structures of the tooth. Little attention has been paid to the effects of mucosal absorption of the sodium bicarbonate in the polishing abrasive. The purpose of this study was to measure any changes in arterial blood chemistry resulting from the use of the Prophy-Jet. The values for pH, sodium, and bicarbonate, as well as other electrolytes, were measured in 10 dogs over a 2 hour period following a 5 minute timed use of the Prophy-Jet. Of all the parameters examined, only the potassium concentration showed a statistically significant change, and the magnitude of this change was not felt to be clinically significant. The pH and concentrations of sodium and bicarbonate remained essentially unchanged with the use of the Prophy-Jet.

Recurrent ischemia more than 1 year after successful percutaneous transluminal coronary angioplasty. An analysis of the extent and anatomic pattern of coronary disease.

Of 1,181 consecutive patients who underwent successful percutaneous transluminal coronary angioplasty (PTCA) as an initial revascularization procedure and who had at least 1 year of asymptomatic follow-up, 66 (6%) underwent repeat angiography because of recurrent symptoms or evidence of exercise-induced ischemia. Patients who had revascularization procedures within 1 year of PTCA were not included in the analysis. Mean time to recurrent ischemia was 30.8 +/- 17.4 months (range 12-89 months). At follow-up, 47 patients had angina, 13 had atypical chest pain, two had acute myocardial infarction, and four had positive exercise tests without symptoms. No patient showed spontaneous regression in the extent of coronary artery disease (CAD). As compared with the extent of CAD immediately after PTCA, the extent of CAD at follow-up did not change in 26 patients (39%); it increased by one vessel in 30 (45%), by two vessels in seven (11%), and by three vessels in three (5%). The pattern of CAD seen at follow-up compared with that seen after PTCA was as follows: 18 patients (27%), no change; seven (11%), restenosis only; 30 (45%), progression of CAD at other sites only; and 11 (17%), a combination of restenosis and progression of CAD at other sites. The time to recurrence of ischemia was significantly different between those with restenosis only versus those with progression only (20.1 +/- 9.2 vs. 38.3 +/- 18.5 months) (p less than 0.009). Progression of CAD was equally distributed between dilated and nondilated vessels; however, when progression occurred in the PTCA vessel, it was significantly more likely to be distal to the PTCA site (p less than 0.008).

Campylobacter pylori, NSAIDS, and smoking: risk factors for peptic ulcer disease.

Campylobacter pylori, nonsteroidal anti-inflammatory drugs, and smoking are associated with ulcer disease. To define further the role of these factors in ulcer disease, one hundred seven subjects presenting for endoscopy were tested for specific IgG and IgA antibodies to C. pylori, and questioned about nonsteroidal use and smoking. Sixty were dyspeptic patients, 28 were disease controls, and 19 were healthy asymptomatic volunteers. Considering all subjects, 81% (87/107) were either taking nonsteroidals or had antibody to C. pylori, and 32% of these (28/87) had an ulcer. Nineteen percent (20/107) were neither taking nonsteroidals nor had antibody to C. pylori, and none of these had an ulcer, p less than 0.01. Smokers, 41% (11/27), were more likely to have an ulcer than nonsmokers, 20% (16/80), p less than 0.05, but only because of the increased prevalence of ulcers in smokers who also had C. pylori, 73% (11/15) versus 27% (12/45) of nonsmokers with C. pylori, p less than 0.01. The use of nonsteroidals and antibody to C. pylori identify people at risk for ulcers. Smoking increases this risk in subjects with C. pylori. Absence of a history of nonsteroidal use and antibody to C. pylori identify individuals with a low probability of ulcer disease.

Minimal resection for bronchogenic carcinoma. Should this be standard therapy?

Minimal resection with curative intent for bronchogenic carcinoma was performed at our institutions in 15 patients from 1977 to 1987. All patients were stage I (T1N0 or T2N0). The five-year actuarial survival was 77 percent. The median length of follow-up for patients remaining alive was 41 months. There was a 6 percent (n = 1) local recurrence rate and a 27 percent (n = 3) distant recurrence rate. Both survival and recurrence rates are similar for minimal resection and for that being reported for lobectomy and pneumonectomy for stage I bronchogenic carcinoma. In our series, both median length of operating time and median length of postoperative hospital stay was less for those patients undergoing minimal resection for stage I bronchogenic carcinoma than for those undergoing lobectomy or pneumonectomy. Minimal resection can be considered as an acceptable treatment for bronchogenic carcinoma when technically possible in selected patients.

Conservative treatment for adenocarcinoma of the pancreas.

The records of 71 patients with the diagnosis of adenocarcinoma of the pancreas were reviewed. Seventeen patients were treated without surgery, 13 underwent exploratory laparotomy for diagnosis with no further palliative or curative operative procedure, six underwent pancreaticoduodenal resection, and 35 patients had a palliative gastric and/or biliary bypass procedure at initial operation. No preoperative signs or symptoms, routine laboratory tests, or radiologic evaluation were helpful as early diagnostic or prognostic indicators. Surgical mortality rates were not significantly different among the four groups; however, the survival time differences between the palliative group (4.8 mo) and the medically managed group (2.0 mo) was significant (p = 0.01 chi 2). Surgical morbidity did not differ significantly among the four groups of patients. The implications of these data in the treatment of patients with adenocarcinoma of the pancreas are discussed.

Duration of amnesia associated with midazolam/fentanyl intravenous sedation.

The purpose of this study was to determine the duration of amnesia associated with the intravenous usage of midazolam and fentanyl. The midazolam was administered in three different dosages based on the patient's weight in kilograms. Patients were shown a series of pen-and-ink drawings at various times throughout the procedure and tested the next day for memory of the drawings using both free recall and match-to-sample paradigms. The results indicate that the low-dosage group (0.07 mg/kg) had insufficient amnesia, whereas the medium (0.10 mg/kg) and high (0.13 mg/kg) groups displayed adequate amnesia in the intraoperative period.

Accuracy of Papanicolaou smears. Art or science?

We examined the relationship between various levels of experience and the ability to obtain adequate Papanicolaou smears as defined by the presence of endocervical cells. From July 1, 1984, through June 30, 1986, 16,360 cervical smears were evaluated for the presence of endocervical cells. Of those smears, 9,243 contained endocervical cells; 7,117 did not. The results were evaluated for seven groups of providers: professional staff, residents (postgraduate years 1-4), nurse practitioners and student nurse practitioners. The range of smears with endocervical cells for individual providers was 22.2-73.1%. Significant differences existed between all the groups. Longer training did not equate with greater skill in obtaining endocervical cells. Obtaining adequate smears appears to be as much an art as a science.

The effect of an air-powder abrasive instrument on composite resin.

Three composite resins were subjected to applications of sodium bicarbonate with an air-powder abrasive instrument. Materials tested were a microfilled, a conventional, and a light-cured composite resin. Samples were tested for surface roughness before and during applications. The applications produced significant increases in roughness. It was concluded that the light-cured composite resin should be the material used for patients undergoing a recall maintenance program in which the instrument is used.

Long-term nutritional assessment of patients with esophageal atresia and/or tracheoesophageal fistula.

Fifty-three patients operated for esophageal atresia and/or tracheoesophageal fistula at the Childrens Hospital of Los Angeles returned for long-term nutritional assessment. The ages ranged from 11 months to 31 years of age with a mean age of 9 years 11 months. Nineteen percent of the patients were below the third percentile in height for their age, thus exhibiting evidence of chronic malnutrition. No significant differences could be demonstrated between patients with a birth weight above or below 2500 g or above or below 5 years of age. Patients over 13 years of age demonstrated considerably less evidence of chronic malnutrition (p less than .06), thus exhibiting a "catch-up" growth phenomenon. Associated anomalies and illnesses were frequently seen in patients with the most significant abnormal nutritional-assessment parameters. Nutritional assessment should be part of long-term management and follow-up of all patients with esophageal atresia or other congenital surgical anomalies.

Stroma-free methemoglobin solution as an antidote for cyanide poisoning: a preliminary study.

Effective treatment of cyanide poisoning requires rapid diagnosis, good supportive treatment and the use of a specific antidote. The currently available antidotes offer demonstrated efficacy along with significant potential adverse side effects. We have investigated an alternate approach to antidote therapy for cyanide poisoning by using Stroma-Free Methemoglobin Solution ( SFMS ). Rats injected with an LD100 intravenous dose of cyanide were treated with SFMS equal to 1.5% of their total body hemoglobin. There was a highly significant increase in the survival rate of the treated group compared to saline controls. The potential advantages of SFMS over current antidotes include an immediate onset of action, rapid elimination of cyanide from the body and a mode of action that doesn't compromise any of the patients' oxygen carrying capacity. SFMS shows promise as a significant adjunct in the treatment of cyanide poisoning.