Management of Wilms' tumor with intracardiac extension.

We review our experience and the literature in treating 4 patients with Wilms' tumor (WT) with intracardiac extension among 92 patients with this neoplasm. Cardiopulmonary bypass with circulatory arrest and profound hypothermia was used. There were 3 boys (3 years, 4 years 5 months, and 15 years) and 1 girl (6 years). The follow-up periods were 8 months, 3 years, 2 years 6 months, and 15 years, respectively. We had no surgical complications and conclude that the preoperative diagnosis is extremely important. These patients must be transferred to institutions where concomitant cardiac procedures can be performed. In treating patients with WT, Doppler ultrasound must be used preoperatively in all cases, not only those in which clinical and radiologic signs of intravascular involvement are found. We propose that preoperative chemotherapy should be used, as it shrinks the thrombus and causes desirable adherence of the thrombus to the venous wall, reducing the probability of thromboembolism during the surgical procedure. We also find this method safer than in our 1st case, where neither cardiac arrest nor hypothermia was used. Our results agree with the literature that intracardiac extension of WT does not worsen its prognosis when a rational surgical approach is used.

[Myocardial revascularization without extracorporeal circulation. Surgical results in 1090 patients]. / Revascularização miocárdica sem circulação extracorpórea. Resultados cirúrgicos em 1090 pacientes.

PURPOSE: To report our experience of 12 years of myocardial revascularization without cardiopulmonary bypass (CPB) and to discuss its expanding surgical indications. METHODS: This technique was employed in 1090 patients, between September/81 and April/93, corresponding to 17.4% of all revascularized patients. Regarding gender, male patients were the majority (73.7%) and ages ranged from 28 to 86 year-old (mean 57). Chronic coronary insufficiency was the main indication (69.4%) and 18.9% of our global experience were operated on during acute ischemia. The average number of grafts per patient was 1.6 and internal mammary artery was utilized in 60.1% of patients. Left anterior descending coronary artery and right coronary artery were the coronary arteries most often treated. RESULTS: Our hospital mortality rate was 2.5% (28/1090) although it was 7% for patients over 70 years. The most common cause of death was cardiogenic shock after failed angioplasty. Postoperative complications included AMI in 4.8%, arrhythmias in 5.5% and pulmonary in 3.2%. Mean of any type of blood derivate utilization was 0.28 units/patients. CONCLUSION: Myocardial revascularization without CPB is a valid alternative in a selected cohort of patients and it is performed with low morbidity and mortality. Nowadays it represents an excellent tactical option for high-risk patients and in failed angioplasties.

[Late development of congestive heart failure in interventricular communication caused by penetrating wound, with pulmonary hypertension resolution after surgical correction]. / Desenvolvimento tardio de insuficiência cardíaca congestiva em comunicação interventricular por ferimento penetrante, com resolução da hipertensão pulmonar após correção cirúrgica.

Male, 33 years-old, with onset of heart failure and edema; he used to be completely asymptomatic but mentioned he underwent previously a pleural drainage, after a hemothorax provoked by a stab wound. His physical examination confirmed he was in heart failure and showed a harsh holosystolic murmur between mitral and tricuspid areas. Cardiac catheterization demonstrated a large apical ventricular septal defect (VSD) and systemic pulmonary arterial pressures. With oxygen there was an increase in the left to right shunt and normal pulmonary vascular resistance. The clinical diagnosis was that of a traumatic VSD provoking pulmonary hypertension although a congenital etiology could not be completely ruled out. At surgery there was a sharp cut at the pericardium and an apical epicardial lesion; the VSD was patch sutured and the patient did well with control of his heart failure. A control hemodynamic study performed within the first postoperative month showed no residual shunt and complete normalization of the pulmonary pressures and resistance.

An overview of medical cost containment in workers' compensation.

Use of medical cost-containment strategies in workers' compensation is increasingly common and varies in design and enforcement. An evolution toward managed care is observed, particularly in the private sector.

Self-reports of spousal violence in a Mexican-American and non-Hispanic white population.

As part of a survey of Los Angeles households, 1,243 Mexican Americans and 1,149 non-Hispanic whites were surveyed about their experiences of spousal violence. Questions to assess violence included both perpetration (whether they had been physically violent toward a partner) and victimization (whether they had been the victim of sexual assault by a partner). Over one-fifth (21.2%) of the respondents indicated that they had, at one or more times in their lives, hit or thrown things at their current or former spouse or partner. Spousal violence rates for Mexican Americans born in Mexico and non-Hispanic whites born in the United States were nearly equivalent (20.0% and 21.6%, respectively); rates were highest for Mexican Americans born in the United States (30.9%). While overall rates of sexual assault were lower for Mexican Americans, one-third of the most recent incidents reported by Mexico-born Mexican-American women involved the husband and approximated rape.

Six-month prevalence of specific psychiatric disorders among Mexican Americans and non-Hispanic whites in Los Angeles.

The current prevalence of DSM-III psychiatric disorders was assessed using the Diagnostic Interview Schedule (DIS) as part of a Los Angeles household population survey. The Los Angeles prevalence estimates were compared with sex- and age-adjusted estimates from four other US field sites, all of which were part of the Epidemiologic Catchment Area (ECA) program. Overall, few significant differences in household population rates were found between Los Angeles and the other ECA sites. Within the Los Angeles household sample, the current prevalence of disorder among Mexican Americans was compared with that among non-Hispanic whites. Non-Hispanic whites had higher rates of drug abuse/dependence than Mexican Americans; the rates among non-Hispanic whites in Los Angeles were also higher than those found at other ECA sites. Mexican Americans displayed higher rates of severe cognitive impairment, a finding that likely reflects ethnic and educational bias in the measurement of cognitive impairment. Another ethnic difference was found only for one specific age and sex group: Mexican-American women 40 years of age or older had strikingly high rates of phobia.