Urethral sensation following reconstructive pelvic surgery.

INTRODUCTION AND HYPOTHESIS: Most urethral neuromuscular function data focus on efferent rather than afferent innervation. We aimed to determine if changes exist in urethral afferent nerve function before and after reconstructive pelvic surgery (RPS). Secondarily, we compared afferent urethral innervation in women with and without stress urinary incontinence undergoing RPS. METHODS: Participants underwent current perception threshold (CPT) and urethral anal reflex (UAR) testing prior to surgery and again post-operatively. Wilcoxon signed ranked test and Spearman's correlations were used and all tests were two-sided. p = 0.05 was considered to indicate statistical significance. RESULTS: Urethral CPT thresholds increased significantly after RPS, consistent with decreased urethral afferent function. Pre-operative urethral CPT thresholds at 5 and 250 Hz were lower in SUI women (10 [IQR 5-29], 40 [32-750]) compared with continent women (63 [14-99], 73 [51-109]; p = 0.45, p = 0.020), signifying increased urethral sensation or easier activation of urethral afferents in SUI women. CONCLUSIONS: Reconstructive pelvic surgery is associated with a short-term deleterious impact on urethral afferent function, as demonstrated by the higher levels of stimuli required to activate urethral afferent nerves (decreased urethral sensation) immediately after RPS. Women with SUI required lower levels of stimuli to activate urethral afferent nerves prior to RPS, although UAR latencies were similar regardless of concomitant SUI.

Semantic category priming in the left cerebral hemisphere.

The representation of semantic codes in the cerebral hemispheres and the interhemispheric communication of these codes, was investigated in two priming experiments where prime and target words were independently projected to the left or right visual fields (LVF or RVF). Nonassociated category exemplars were employed as related pairs in a lexical decision task and separated by a stimulus onset asynchrony of 250 msec in Experiment 1 and 450 msec in Experiment 2. Both experiments obtained priming effects when primes and targets were both projected to the RVF, but not the LVF. Semantic category primes projected to the RVF also facilitated responses to LVF targets, but no LVF-RVF priming was obtained. This suggests that semantic category information is relayed from left to right hemisphere, but not vice versa. The results are consistent with the view that semantic categories are represented in the left hemisphere.

Low-dose methotrexate as an adjunctive therapy with surgery for ectropion complicating dermatomyositis.

We describe the clinical and histopathologic features of a 44-year-old woman who developed bilateral lower eyelid ectropion and upper lid entropion presumably secondary to dermatomyositis. A variety of inflammatory, infiltrative and/or scarring dermatoses have been associated with ectropion. Chronic inflammation, poikilodermatous change and mucinous infiltration of the eyelids due to dermatomyositis are the postulated mechanisms leading to ectropion in our patient. This case is unique in that neither dermatomyositis nor papular mucinosis has previously been reported as a cause of ectropion. Also interesting was the adjunctive effect of methotrexate therapy.

Widespread cutaneous necrosis as the initial manifestation of the antiphospholipid antibody syndrome.

We describe a patient with the acute onset of widespread cutaneous necrosis as the initial manifestation of the antiphospholipid antibody syndrome (APS). The patient was effectively treated with corticosteroids and anticoagulants, however extensive skin grafting was eventually required. We review 6 other reported cases and discuss the various underlying etiologies of vascular thrombosis resulting in cutaneous necrosis. Early recognition and treatment of the APS may limit the extent of thrombotic complications that can result in tissue necrosis.

Doppler echocardiography and the early diagnosis of carditis in acute rheumatic fever.

BACKGROUND: The incidence of acute rheumatic fever in New Zealand remains relatively high. Reliable early diagnosis of carditis is difficult and important in management. AIM: To determine if Doppler echocardiography contributed to the early diagnosis of carditis in acute rheumatic fever. METHODS: Forty-seven patients admitted to hospital with suspected acute rheumatic fever and 19 control patients, with a febrile illness due to a documented non-cardiac bacterial infection, were assessed two days and two weeks following admission. Presence or absence of clinical carditis was determined by a cardiologist unaware of the suspected diagnosis, from clinical examination, chest radiograph, electrocardiogram (ECG) and two dimensional echocardiogram. Doppler echocardiography was then performed and interpreted by a second cardiologist unaware of the diagnosis. After completion of the study the Jones criteria were applied, to categorise the patients with suspected acute rheumatic fever into four groups for the final diagnosis: no acute rheumatic fever, possible acute rheumatic fever, definite acute rheumatic fever without carditis, and definite acute rheumatic fever with carditis. RESULTS: In 19 patients with a final diagnosis of acute rheumatic fever and carditis at the baseline assessment carditis was detected by clinical assessment in 15 patients, compared with 19 patients with evidence of significant valve regurgitation by Doppler echocardiography. Following the two week assessment, all 19 patients had both clinical and Doppler evidence of carditis. Five patients with a final clinical diagnosis of possible acute rheumatic fever or definite acute rheumatic fever without carditis, had a Doppler abnormality detected. There was no clinical or Doppler abnormality in the febrile controls. CONCLUSIONS: Doppler echocardiography is more sensitive than clinical assessment in the detection of carditis in acute rheumatic fever, and can contribute to earlier diagnosis.

Picture-name priming in the cerebral hemispheres.

In a lexical decision task, pictures and names of common objects were presented in succession to the left or right visual fields in an investigation of the relationship between visual and verbal representations within and between the hemispheres. On each trial, a picture was projected to the left or right side of the visual field, followed by a string of letters to the same or different side. The letter string could be the name of the object in the picture, an unrelated word, or a nonword. Although a strong priming effect was observed when the name of an object followed its picture, this did not depend on which visual fields had registered the stimuli. Activation of name codes was apparently independent of visual field of presentation of picture and word. This result was consistent with the view that representational systems for pictures and their names are not differentially specialized across the hemispheres. A further finding was that absolute response time to words was shorter when stimuli were divided between the visual fields, even at an SOA of 1000 msec. It is suggested that this result is due to the activation of picture-processing mechanisms within a hemisphere by the first (pictorial) stimulus, which causes a delay in processing the subsequent verbal stimulus in that hemisphere.

Associative priming in the hemispheres as a function of SOA.

The representation of associative codes in the cerebral hemisphere was investigated in two priming experiments where associated prime and target words were independently projected to the left or right visual fields. The first experiment, using a stimulus onset asynchrony of 250 msec, found priming in all visual field conditions, except that in which both prime and target were projected to the right hemisphere. A second experiment was conducted to determine whether this absence of right hemisphere priming was due to an inadequate interval of time between prime and target. In this experiment, a stimulus onset asynchrony of 450 msec revealed significant priming in all visual field conditions. The results suggest that lexical representations are activated more slowly in the right hemisphere than in the left.

Noncollagenous (NC1) domain of collagen VII resembles multidomain adhesion proteins involved in tissue-specific organization of extracellular matrix.

Type VII collagen (C7) is a stratified squamous epithelial basement membrane protein composed of three identical alpha chains, each consisting of a 145-kDa amino-terminal noncollagenous (NC1) domain and a 145-kDa carboxyl-terminal collagenous domain. Morphologic and biochemical studies have shown that tissue-specific aggregates of C7 dimers called anchoring fibrils may contribute to epithelial basement membrane organization and adherence by interacting with extracellular matrix (ECM) proteins such as type IV collagen. In this study, we cloned a cDNA encoding most of the NC1 domain of C7. The deduced amino acid sequence revealed motifs characteristic of multidomain ECM proteins that contribute to the tissue-specific organization of ECM including a region of 7 1/2 sequential fibronectin type III (Fn III) homology repeats, a potential collagen-binding region homologous to the A domain of von Willebrand factor (vWf) and an RGD sequence. A purified C7 fusion protein containing these motifs specifically bound to type IV collagen in a functional assay. These results suggest that regions within the NC1 domain of C7 mediate interactions with lamina densa and dermal ECM proteins including type IV collagen. Structural mutations and autoepitopes in these regions may represent mechanisms for the development of defective basement membrane organization and adherence in genetic and autoimmune forms of epidermolysis bullosa.

Acute nutmeg intoxication.

Nutmeg is a common household spice sometimes abused for its hallucinogenic properties. This abuse is well reported in the medical literature over the last century. Ingestion of less than one tablespoon can produce symptoms similar to those of an anticholinergic toxic episode. Common presenting complaints are hallucinations, palpitations, and feelings of impending doom. We report a case of intentional nutmeg intoxication in a 23-year-old college student. As laboratory tests are usually normal, this diagnosis should be considered in patients presenting with an acute psychotic break accompanied by symptoms resembling an anticholinergic toxic episode. Treatment is primarily supportive once other life-threatening conditions have been ruled out.

Flight physiology. Clinical considerations.

Altitude-related complications and the stresses of flight represent the components of flight physiology. Understanding the complexities associated with patient management relative to barometric pressure changes and hypoxia is of paramount concern to air medical personnel. This article reviews flight physiology as well as appropriate precautions and interventions that must be practiced to provide optimal patient care at various altitudes.

Echocardiographic prediction of left ventricular volume after myocardial infarction.

Left ventricular volume is a strong determinant of survival after acute myocardial infarction. The aim of this study was to determine which clinical and echocardiographic criteria assessed early after myocardial infarction would predict later left ventricular dilation. Forty-eight patients with uncomplicated transmural myocardial infarction had echocardiography 5 to 10 days after myocardial infarction and assessment of clinical variables including peak creatine kinase and sum of electrocardiographic ST segment elevation. Left ventricular dimensions were measured from the echocardiogram in the parasternal view and also in the apical four and two chamber views at the level of the mitral leaflets, papillary muscles and apex. A cardiac wall motion score was obtained by segmental analysis of the apical views. Echocardiographic left ventricular volume was measured after 1 year from the apical views with use of a Simpson's rule method. Initial clinical and echocardiographic variables were correlated with the left ventricular volume at 1 year. There was a significant relation between the initial four and two chamber end-diastolic dimensions and the left ventricular volume at 1 year, particularly for dimensions measured at the apical level (four chamber R2 = 0.66, p = 0.0001, two chamber R2 = 0.61, p = 0.0001). Other clinical variables, parasternal left ventricular dimensions and cardiac wall motion score were not significantly related to left ventricular volume. A powerful three variable model obtained by multiple regression and including the initial two chamber apical dimension, cardiac wall motion score and body surface area accounted for 82% of the variation in left ventricular volume at 1 year.

A double-blind, vehicle-controlled study evaluating masoprocol cream in the treatment of actinic keratoses on the head and neck.

This double-blind, vehicle-controlled, multicenter study evaluated the efficacy and safety of a new topical antineoplastic agent, masoprocol, in the treatment of actinic keratoses of the head and neck. Of the 113 patients who applied topical masoprocol twice a day for 14 to 28 days, there was a mean decrease in actinic keratoses from 15.0 to 5.4 and a median percent reduction from baseline actinic keratosis count of 71.4% at the 1-month follow-up visit. Comparable numbers for the vehicle-treated group were 13.4 to 11.1 actinic keratoses and 4.3% median percent reduction. Irritation, as manifested by erythema or flaking, occurred in 61.5% of topical masoprocol-treated patients versus 26.7% of those treated with vehicle and did not correlate with clinical response. Topical masoprocol appears to be useful in the treatment of actinic keratoses.

Semantic and phonemic priming in the cerebral hemispheres.

Representation of semantic and phonemic codes in the cerebral hemispheres was investigated in two priming experiments where prime and target words were independently projected to the left or right visual fields. The first experiment, using phonemic primes, confirmed the view that phonological information is not accessible to the right hemisphere. Priming effects were obtained only when the prime and target were both projected to the right visual field. The second experiment, employing category exemplars as primes, again found the left hemisphere to be the principal locus of the priming effects. The right hemisphere was unable, by itself, to activate words related to the exemplar prime. However, projection of the prime to the right visual field significantly facilitated responses to left visual field targets. The present findings support the view advanced by Drews (Neuropsychologia 25, 419-427, 1987) and Levy and Trevarthen (J. exp. Psychol., Hum. Percep. Perform. 2,299-312, 1976) that the left lexicon is structured in accordance with an hierarchy of logical semantic relationships, while the right lexicon is organized on the basis of simple associations between concepts. It is suggested, furthermore, that the patterns of semantic, but not phonological, activation invoked by a prime may be relayed between the two lexicons.

The design and implementation of a management information system for Australian public hospitals.

Existing management information systems (MIS) in hospitals are often inadequate. This has occurred because of a variety of antecedents, including past funding mechanisms, organisational structure and the accepted role of management. A variety of new pressures, including demands for increased accountability, greater resource control and changing relationships between physicians and hospitals are demanding improved MIS to enable the hospital to manage. This paper explores these influences on past and future hospital MIS. It describes the design of a MIS that enables patient care to be costed in clinically meaningful ways. Patient costs may be aggregated to cost specific diagnoses and procedures, Diagnosis Related Groups (DRG), a clinician's case load, a clinical unit or a division. The information can be used for clinical budgeting, flexible budgeting, utilisation review and quality assurance.

Needle localization biopsy of occult lesions of the breast. Experience in 199 cases.

From January 1980 through June 1986, 199 percutaneous needle localizations for clinically occult breast lesions were performed at North Carolina Memorial Hospital. A retrospective analysis of the medical records, mammograms, operative notes, and pathology reports was undertaken to evaluate the success of this procedure. In our series, biopsy was prompted by abnormal calcifications in 27.1% of lesions, occult masses in 37.2%, and by a combination of occult masses and microcalcification in 35.7%. Overall, we had a yield of positive biopsies for cancer of 16.3%, with the yield improving from 12.3% in the earlier years of our study, to 18.7% in the latter years. Of the cancer cases detected, 89.7% were stage I. The localization procedure was successful in 95.9% of the cases. Analysis of our eight failures, along with a review of the literature, shows the major reasons for failure to be incomplete removal of areas with multiple calcifications, dislodgement of the needle, and problems resulting from lack of communication between the radiologist and surgeon. We conclude that the failure rate is low, the yield good, and needle localization a worthwhile procedure for localizing nonpalpable occult lesions.