Treatment of acute stroke with hyperbaric oxygen: time window for efficacy.

We conducted a retrospective statistical analysis of the Heyman, Saltzman, Whalen 1966 study of 22 stroke patients treated with hyperbaric oxygen (HBO2)--13 of them one to five hours post-stroke. We examined patients who received HBO2 treatment within seven hours post-stroke. An exploratory logistic regression analysis examining the influence of time post-stroke, time in chamber and dose of HBO2, range 2.02 atmospheres absolute (ATA) to 3.04 ATA, was conducted. Only time post-stroke was a significant influence for recovery, with each passing hour decreasing the chance of at least partial transient recovery by 62% - odds ratio: 0.38 (95% CI: 0.15 -0.95), p = 0.039. In the one- to five-hour group of 13 patients, nine (41% of 22) had recovery or recovery with relapse. This represented 69% (+/- 25% SE) of this time frame. Only two of the nine had permanent recovery. Past six hours poststroke, only one patient (11% +/- 21% SE) had partial recovery with relapse. The other eight past six hours had no recovery at all. The first three hours post-stroke HBO2 administration has the most promise for efficacy and improvement of rtPA therapy. HBO2 may also prove to be a useful challenge pre-rtPA administration to assess the risk-benefit ratio for giving rtPA.

Coping with stress during childhood and adolescence: problems, progress, and potential in theory and research.

Progress and issues in the study of coping with stress during childhood and adolescence are reviewed. Definitions of coping are considered, and the relationship between coping and other aspects of responses to stress (e.g., temperament and stress reactivity) is described. Questionnaire, interview, and observation measures of child and adolescent coping are evaluated with regard to reliability and validity. Studies of the association of coping with symptoms of psychopathology and social and academic competence are reviewed. Initial progress has been made in the conceptualization and measurement of coping, and substantial evidence has accumulated on the association between coping and adjustment. Problems still remain in the conceptualization and measurement of coping in young people, however, and aspects of the development and correlates of coping remain to be identified. An agenda for future research on child-adolescent coping is outlined.

A statewide survey of age at first intercourse for adolescent females and age of their male partners: relation to other risk behaviors and statutory rape implications.

In a statewide survey of a representative sample of adolescent girls in 8th-12th grades (N = 4201), information was obtained on age at first intercourse and age of their male partners. Excluding intercourse experiences where physical force was threatened or used, 31% had intercourse by age 15 and 45% by age 16. Contrary to the impression left by studies of teenage mothers, girls who first had sex between age 13 and age 15 or between age 16 and age 18 did not have a large percentage of much older partners (5 or more years older; 12 and 7%, respectively). The percentage of much older partners was higher, however, for girls who had sex in very early adolescence, ages 11-12 (34%). Much older male partners were associated with greater problem behaviors for girls who first had intercourse in very early adolescence (11-12), but less so for those who first had intercourse between age 13 and age 15 (truancy only) and not at all for those who first had intercourse at between 16 and 18. Regardless of partner's age disparity, earlier age at first intercourse during adolescence was associated with a greater number of other problem behaviors. The implications of these findings for recent calls to enforce statutory rape laws more stringently to reduce teenage pregnancy were discussed.

Housing quality and mental health.

This study examined the potential link between housing quality and mental health. First, the development of a psychometrically sound, observer-based instrument to assess physical housing quality in ways conceptually relevant to psychological health is reported. Then 2 different studies, including a prospective longitudinal design, demonstrate that physical housing quality predicts mental health. Possible underlying psychosocial processes for the housing quality-psychological distress link are discussed.

Responses to stress in adolescence: measurement of coping and involuntary stress responses.

The development of a measure of coping and involuntary stress responses in adolescence is described. The Responses to Stress Questionnaire (RSQ) reflects a conceptual model that includes volitional coping efforts and involuntary responses to specific stressful events or specified domains of stress. The psychometric characteristics of the RSQ were examined across 4 domains of stress in 3 samples of adolescents and parent reports obtained in 2 samples. The factor structure of the RSQ was tested and replicated with an adequate degree of fit using confirmatory factor analysis across 3 stressors in 2 samples. Internal consistency and retest reliability for the 5 factors were adequate to excellent. Concurrent validity was established through correlations with another measure of coping, heart rate reactivity, and correlations of self- and parent-reports. Significant correlations with both adolescents' and parents' reports of internalizing and externalizing symptoms were consistent with hypotheses.

Detection of deep venous thrombosis: prospective comparison of MR imaging and sonography.

Seventy-five patients (41 women and 34 men, 20-85 years old) with clinically suspected deep venous thrombosis (DVT) were examined with MR imaging and sonography. In 26 patients, the final diagnosis was acute femoropopliteal DVT. The sensitivity of MR imaging for detecting this disease was 100% with a 95% confidence interval (CI) of 87-100%; the specificity was 100% with a CI of 92-100%; and the accuracy was 96% with a CI of 89-99%. The correspond-ing sensitivity of sonography was 77% with a CI of 53-92%; the specificity was 98% with a CI of 89-100%; and the accuracy was 83% with a CI of 72-90%. In four of the 75 patients, MR images revealed thrombus of the pelvis (n = 1) or calf (n = 3) without femoropopliteal involvement. The estimated prevalence of isolated calf and/or pelvic DVT was 5% with a CI of 1-13%. MR imaging is significantly more sensitive (P = .02) and accurate (P < .01) than sonography in the detection of lower extremity DVT, but there was no difference in the specificity of MR imaging and that of sonography (P = .31).

Diagnosis and management of acute pulmonary embolism. Past, present, and future.

The diagnosis and management of acute pulmonary embolism continues to evolve as new diagnostic modalities develop and become refined and as experience is gained with prevention and therapy. This article describes some of the milestones in the development of diagnostic modalities and some useful diagnostic and therapeutic techniques that may become practical in the future.

Pulmonary angiography with MR imaging: preliminary clinical experience.

PURPOSE: To study the accuracy of magnetic resonance (MR) pulmonary angiography in 20 patients in whom pulmonary embolism (PE) was clinically suspected. MATERIALS AND METHODS: Fourteen patients (group 1) were recruited for the MR pulmonary angiography study before they underwent conventional pulmonary angiography (CPA) based on clinical findings. Six patients (group 2) did not undergo CPA but were considered to have PE on the basis of findings in other studies. MR venography was performed at the time of MR pulmonary angiography in 13 patients. RESULTS: MR pulmonary angiography had a sensitivity of 92%-100% and specificity of 62% for detection of PE. Performance of MR pulmonary arteriography and MR venography in a single examination to demonstrate thrombus in both the arterial and deep venous systems was proved feasible. CONCLUSION: This report describes an early clinical implementation of new MR pulmonary angiographic techniques. Further advances to improve specificity by enhancing sensitivity to slow flow and increasing spatial resolution are necessary before routine clinical use of MR pulmonary angiography is justified.

Strategy for diagnosis of patients with suspected acute pulmonary embolism.

STUDY PROTOCOL: Two separate groups of clinical investigators have provided new information and divergent approaches to the management of acute pulmonary embolism (PE). In this position paper, investigators from both groups (Prospective Investigation of Pulmonary Embolism Diagnosis [PIOPED] and Canadian study groups) have utilized the combined scientific database in order to rationalize seemingly polarized diagnostic recommendations into a single practical algorithm. METHODS: An in-depth review established the relative risks of deep venous thrombosis (DVT) and the related accuracy of diagnostic tests. In PIOPED, 640 of 887 patients at risk for PE had either an intermediate probability ventilation/perfusion (V/Q) scan or a V/Q scan probability that was discordant with the prior estimate of probability by clinical assessment. The risk of PE in these patients was 16 to 88 percent (average, 34 percent). In this group, we calculated the probability of PE assuming that tests for DVT had been performed and that 50 percent of patients with PE have detectable proximal DVT. By calculation, 108 in 640 patients of whom the diagnosis of PE was uncertain, would have shown proximal DVT. In 239 of these 640 patients, tests for DVT would have been negative and the risks of PE in these patients is calculated to be less than 10 percent. RESULTS: Therefore, we calculate that in 347 of 640 patients, confident recommendations for treatment or no treatment could have been given without pulmonary angiography. Accordingly, in the PIOPED study group of 887 patients, the need for pulmonary angiography would have been reduced from 640 (72 percent) to 293 patients (33 percent). CONCLUSION: In conclusion, a diagnostic strategy that includes the clinical evaluation, V/Q scan, and evaluation for DVT would decrease the number of patients who require pulmonary angiography from 72 to 33 percent.

Shark oil pneumonia. An overlooked entity.

Nonprescription drugs are often believed to be innocuous. We present a case of lipoid pneumonia from ingestion of squalene, a derivative of shark liver oil, a popular over-the-counter Asian folk remedy.

The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease.

The clinical features and noninvasive tests, including ventilation perfusion (V/Q) lung scans, were assessed in 108 patients with chronic obstructive pulmonary disease (COPD) suspected of having pulmonary embolism (PE). Twenty-one (19 percent) of 108 patients had PE. In the majority of patients, it was impossible to distinguish between patients with and without PE by clinical assessment alone. However, when a high clinical index of suspicion was present, PE was confirmed by angiography in three of three patients, but the V/Q scan was of intermediate probability. No roentgenographic abnormalities distinguished between PE and no PE. There was no difference between the alveolar-arterial oxygen gradients in either group, nor was there evidence of a reduction in the PaCO2 in patients with PE who had prior hypercapnia. Among the 108 patients with COPD, high, intermediate, low, and normal/near normal probability scans were present in 5 percent, 60 percent, 30 percent, and 5 percent, respectively. The frequency of PE in these V/Q scan categories was five (100 percent) of five, 14 (22 percent) of 65, two (6 percent) of 33, and zero (0 percent) of five, respectively. In conclusion, in the majority of patients, the V/Q scan diagnosis is usually intermediate and such patients require further investigational studies, including angiography. However, among the few patients who demonstrated a high probability lung scan, there was a high positive predictive value for PE effectively avoiding the need for further studies. In those patients with low probability or near normal/normal V/Q scans, the negative predictive value was not lower than the general hospital population.

Complications and validity of pulmonary angiography in acute pulmonary embolism.

BACKGROUND: The Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) addressed the value of ventilation/perfusion scans in acute pulmonary embolism (PE). The present study evaluates the risks and diagnostic validity of pulmonary angiography in 1,111 patients who underwent angiography in PIOPED: METHODS AND RESULTS: Complications were death in five (0.5%), major nonfatal complications in nine (1%), and less significant or minor in 60 (5%). More fatal or major nonfatal complications occurred in patients from the medical intensive care unit than elsewhere: five of 122 (4%) versus nine of 989 (1%) (p less than 0.02). Pulmonary artery pressure, volume of contrast material, and presence of PE did not significantly affect the frequency of complications. Renal dysfunction, either major (requiring dialysis) or less severe, occurred in 13 of 1,111 (1%). Patients who developed renal dysfunction after angiography were older than those who did not have renal dysfunction: 74 +/- 13 years versus 57 +/- 17 years (p less than 0.001). Angiograms were nondiagnostic in 35 of 1,111 (3%), and studies were incomplete in 12 of 1,111 (1%), usually because of a complication. Surveillance after negative angiograms showed PE in four of 675 (0.6%). Angiograms, interpreted on the basis of consensus readings, resulted in an unchallenged diagnosis in 96%. CONCLUSIONS: The risks of pulmonary angiography were sufficiently low to justify it as a diagnostic tool in the appropriate clinical setting. Clinical judgment is probably the most important consideration in the assessment of risk.

Diagnosis of acute pulmonary embolism in the elderly.

The diagnostic features of acute pulmonary embolism among 72 patients greater than or equal to 70 years old were evaluated and compared with characteristics of pulmonary embolism among 144 patients 40 to 69 years and 44 patients less than 40 years old. Syndromes characterized by either 1) pleuritic pain or hemoptysis, 2) isolated dyspnea, or 3) circulatory collapse were observed with comparable frequency among patients greater than or equal to 70 years old and younger patients. One of these presenting syndromes occurred in 64 (89%) of the 72 patients greater than or equal to 70 years old. Those who did not show these syndromes were identified on the basis of unexpected radiographic abnormalities, which may have been accompanied by tachypnea or a history of thrombophlebitis. Among the 72 patients greater than or equal to 70 years with pulmonary embolism, dyspnea or tachypnea (respirations greater than or equal to 20/min) occurred in 66 (92%), dyspnea or tachypnea or pleuritic pain in 68 (94%) and dyspnea or tachypnea or radiographic evidence of atelectasis or a parenchymal abnormality in 72 (100%). Complications of angiography were evaluated among patients with and without pulmonary embolism. Major complications of pulmonary angiography among patients greater than or equal to 70 years old (2 [1%] of 200) were not more frequent than among younger patients (6 [1.1%] of 562) (p = NS). However, renal failure (major or minor) was more frequent in patients greater than or equal to 70 years old than in younger patients (6 [3%] of 200 versus 4 [0.7%] of 562) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease.

The history, physical examination, chest radiograph, electrocardiogram and blood gases were evaluated in patients with suspected acute pulmonary embolism (PE) and no history or evidence of pre-existing cardiac or pulmonary disease. The investigation focused upon patients with no previous cardiac or pulmonary disease in order to evaluate the clinical characteristics that were due only to PE. Acute PE was present in 117 patients and PE was excluded in 248 patients. Among the patients with PE, dyspnea or tachypnea (greater than or equal to 20/min) was present in 105 of 117 (90 percent). Dyspnea, hemoptysis, or pleuritic pain was present in 107 of 117 (91 percent). The partial pressure of oxygen in arterial blood on room air was less than 80 mm Hg in 65 of 88 (74 percent). The alveolar-arterial oxygen gradient was greater than 20 mm Hg in 76 of 88 (86 percent). The chest radiograph was abnormal in 98 of 117 (84 percent). Atelectasis and/or pulmonary parenchymal abnormalities were most common, 79 of 117 (68 percent). Nonspecific ST segment or T wave change was the most common electrocardiographic abnormality, in 44 of 89 (49 percent). Dyspnea, tachypnea, or signs of deep venous thrombosis was present in 107 of 117 (91 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain or atelectasis or a parenchymal abnormality on the chest radiograph was present in 115 of 117 (98 percent). In conclusion, among the patients with pulmonary embolism that were identified, only a small percentage did not have these important manifestations or combinations of manifestations. Clinical evaluation, though nonspecific, is of considerable value in the selection of patients in whom there is a need for further diagnostic studies.

Diagnostic utility of ventilation/perfusion lung scans in acute pulmonary embolism is not diminished by pre-existing cardiac or pulmonary disease.

The purpose of this study was to assess the impact of prior cardiac or pulmonary disease upon the utility of ventilation/perfusion (V/Q) scans in the diagnosis of acute pulmonary embolism (PE). Ventilation/perfusion scans were evaluated among 365 patients with no prior cardiac or pulmonary disease and compared to V/Q scans in 526 patients with prior cardiac or pulmonary disease. Among patients with no prior cardiac or pulmonary disease, PE was present in 117 and PE was excluded in 248. Among patients with prior cardiac or pulmonary disease, PE was present in 140 and excluded in 386. The positive predictive value for PE of high probability V/Q scans among patients with prior cardiac or pulmonary disease, 55 of 66 (83 percent), was not significantly lower than among patients without prior cardiac or pulmonary disease, 50 of 54 (93 percent) (NS). The positive predictive value of low probability V/Q scans was similar with prior cardiac or pulmonary disease, 25 of 182 (14 percent), and without prior cardiac or pulmonary disease, 17 of 113 (15 percent) (NS), as was the predictive value of near normal/normal V/Q scans, 2 of 51 (4 percent), vs 3 of 79 (4 percent) (NS). The sensitivity of high probability V/Q scans, with pre-existing cardiac or pulmonary disease and without, 55 of 140 (39 percent) vs 50 of 117 (43 percent), did not differ significantly. The specificity of high probability V/Q scans with prior cardiac or pulmonary disease and without, 375 of 386 (97 percent) vs 244 of 248 (98 percent) was also similar (NS). In conclusion, the diagnostic utility of V/Q scans for acute PE was not impaired by the presence of pre-existing cardiac or pulmonary disease. Fewer patients, however, with no prior cardiac or pulmonary disease, had intermediate (indeterminate) V/Q scans.

Usefulness of noninvasive diagnostic tools for diagnosis of acute pulmonary embolism in patients with a normal chest radiograph.

The value of bedside examination and noninvasive tests in the diagnosis of acute pulmonary embolism (PE) among patients with a normal chest radiograph was investigated. Normal chest radiographs were present in 20 of 260 patients (8%) with acute PE and in 113 of 642 (18%) with suspected acute PE, in whom the diagnosis was excluded. A partial pressure of oxygen in arterial blood less than or equal to 70 mm Hg in a dyspneic patient with a normal chest radiograph was more often seen among patients with PE (9 of 17, 53%) than among patients in whom PE was excluded (18 of 93, 19%; p less than 0.01). However, no combinations of blood gases, signs and symptoms were strictly diagnostic. High probability ventilation/perfusion scans among patients with a normal chest radiograph were indicative of PE in only 6 of 9 patients (67%). Among patients with low-probability ventilation/perfusion scans, 8 of 47 (17%) had PE. This study showed that the combination of dyspnea and hypoxia in a patient with a normal chest radiograph is a useful clue to the diagnosis of PE. Although intuition suggested that ventilation/perfusion scans would yield better results in patients with a normal chest radiograph, the ability to diagnose PE by ventilation/perfusion scans in this subset of patients was not enhanced, except by a reduction of the percentage of patients with intermediate probability scans.