Primary (spontaneous) chordal rupture: relation to myxomatous valve disease and mitral valve prolapse.

The excised valves of 152 consecutive patients who underwent isolated primary mitral valve replacement between May 1979 and July 1983 were studied to determine the cause of primary (spontaneous) rupture of the chordae tendineae and estimate the prevalence of floppy mitral valve with underlying myxomatous disease. Of these 152 patients, 72 had nonrheumatic disease; 42 (28% of the total group) had a floppy valve, and 39 of these valves had microscopic changes of myxomatous disease. Primary chordal rupture had occurred in 31 patients, including 29 with myxomatous disease. Seven of these patients had prior documentation of mitral valve prolapse and an additional 20 patients had a long-standing murmur. Ischemic mitral regurgitation (22 patients) accounted for the majority of the remaining 30 patients with nonrheumatic disease. Therefore, approximately half of all isolated mitral valve replacements in this institution are now performed for nonrheumatic disease, the majority for a floppy valve in which myxomatous disease was the underlying abnormality. Primary chordal rupture almost invariably occurs as a complication of myxomatous disease, and mitral valve prolapse may be a common precursor.

The ACC professional life survey: career decisions of women and men in cardiology. A report of the Committee on Women in Cardiology. American College of Cardiology.

OBJECTIVES: This survey was conducted to learn how the career decisions of women and men in cardiology influenced their professional and personal lives. BACKGROUND: Women represent only 5% of practicing adult cardiologists and 10% of trainees. Yet, women and men now enter medical school at nearly equal numbers. The factors that contribute to career satisfaction in cardiology should be identified to permit the development of future strategies to ensure that the best possible candidates are attracted to the profession. METHODS: A questionnaire developed by the Ad Hoc Committee on Women in Cardiology of the American College of Cardiology (ACC) was mailed in March 1996 to all 964 female ACC members and an age-matched sample of 1,199 male members who had completed cardiovascular training. RESULTS: Women were more likely to describe their primary or secondary role as a clinical/noninvasive than invasive cardiologist (p < 0.0001 women vs. men). Men and women both reported a high level of satisfaction with family life, but women were less satisfied with their work as cardiologists (88% vs. 92%, p < 0.01) and with their level of financial compensation. Compared with men, women expressed less overall satisfaction (69% vs. 84%) and more dissatisfaction with their ability to achieve professional goals (21% vs. 9%). These differences were most pronounced for women in academic practice. Women reported greater family responsibilities, which may limit their opportunities for career advancement. Women were more likely to alter training or practice focus to avoid radiation. A majority of women (71%) reported gender discrimination, whereas only 21% of men reported any discrimination, largely due to race, religion or foreign origin. CONCLUSIONS: Women cardiologists report overall lower satisfaction with work and advancement, particularly within academic practice. They report more discrimination, more concerns about radiation and more limitations due to family responsibilities, which may ultimately explain the low percentage of women in cardiology. Attention to these issues may result in programs to improve professional satisfaction and attract the best candidates into cardiology in the future.

Hemiketal formation of dehydroascorbic acid drives ascorbyl radical anion disproportionation.

In this paper the relationship between the ascorbate anion (AH(-)) and its oxidation products, ascorbyl radical anion (A&z.rad;(-)) and dehydroascorbic acid (DHA), are studied by means of theoretical calculations. Additional calculations are performed on alpha-hydroxytetronate, a model compound of ascorbate lacking the side chain. The method uses density functional theory with the B3LYP functional and a polarizable conductor dielectric model to compute solvation effects. Our results indicate that the model compound reacts with the alpha-tocopheroxyl radical to regenerate vitamin E with a free energy change of reaction (in water) of -7.4 kcal/mol. This reaction is 2.9 kcal/mol more exergonic than the corresponding reaction involving ascorbate, suggesting that the model compound may make a more effective antioxidant than ascorbate. However, the disproportionation of the ascorbyl radical anion, a reaction that regenerates AH(-), is found to be exergonic while the similar reaction involving the model compound is slightly endergonic. The reason for the difference is that the disproportionation of A&z. rad;(-) is found to be driven by the formation of the hemiketal structure of dehydroascorbic acid (DHA).

Early and long-term results of coronary artery bypass grafting with severely depressed left ventricular performance.

The effects of coronary artery bypass grafting (CABG) on ventricular performance and long-term clinical status were studied in 18 consecutive patients with disabling angina pectoris and severely depressed left ventricular (LV) performance (ejection fraction [EF] 27 +/- 9%). All patients survived CABG, although 1 patient had a perioperative myocardial infarction. There was no change in LVEF at rest, 29 +/- 12%, in the other 17 patients. However, LVEF during peak exercise increased from 22 +/- 7% to 27 +/- 14% (p less than 0.05). The 17 patients were separated into 2 groups: those who increased their peak exercise LVEF by at least 10% (group A, 8 patients) and those who increased it by less than 10% (group B, 9 patients). Preoperatively, patients in group A had a higher LVEF at rest (p less than 0.001) and smaller end-systolic and end-diastolic volumes at rest (p less than 0.001) and during exercise (p less than 0.005). Preoperatively, the LVEF in group A decreased with exercise, from 36 +/- 4% to 27 +/- 5% (p less than 0.01), but was unchanged in group B (19 +/- 3% vs 17 +/- 4%, difference not significant). After CABG, patients in group A had a smaller increase in end-systolic volume with exercise than those in group B (13 +/- 7 vs 34 +/- 22 ml/m2, p less than 0.05), but the changes in end-diastolic volume with exercise were not significantly different. At 27 +/- 5 months after CABG, 5 of 8 patients in group A were asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)

Ligation of the patent ductus. Technical considerations at different ages.

Over a 10 year period, 185 patients have been treated for patent ductus, including nine premature infants with a respiratory distress syndrome. Thirty-five other infants have had duct obliteration during the neonatal period, the incidation for surgery being intractable heart failure. Six of 18 adults had calcification or aneurysm in the duct region. three of these required extracorporeal circulation for duct control and closure. The remaining patients were from 1 to 18 years of age and underwent elective duct obliteration. Double ligation of the duct is regarded as the simplest, safest, and quickest technique generally applicable. Special techniques are required for fragile, broad, calcified, hypertensive, and conical ducts.

Deep hypothermic arrest: observations on later development in children.

Thirty-two children were reviewed following closure of ventricular septal defect in infancy. Fifteen had undergone continuous perfusion and 17 had been subjected to core cooling followed by deep hypothermic arrest. Parental and professional evaluations of intellectual and motor development, at periods between 7 and 72 months following operation, suggest that there is a higher incidence of developmental abnormality in the subgroup treated with deep hypothermic arrest.

Some advantages of the membrane oxygenator for open-heart surgery.

The Lande'-Edwards oxygenator has been used for clinical perfusions on 283 patients. Among these patients we have encountered the full range of congenital and acquired defects and a variance in age from 1 day to adulthood. Data are presented concerning the means and methods of perfusion, the defects involved, and the results of treatment. A comparison has been made between two groups of 20 adults each, one group perfused with a bubble oxygenator (Bently) and the other with the Lande'-Edwards membrane lung. This study showed that platelet function is better preserved by the membrane lung, that hemolysis is less severe, and that postoperative bleeding is reduced. Indirect evidence has been accumulated to suggest that pulmonary, cerebral, and renal function is also better preserved when the membrane lung is employed.

A comparative analysis of rural and urban mortality in Georgia, 1979.

This paper examines the relationship between mortality and ruralness in the state of Georgia. In 1979, the rural Standardized Mortality Ratio (SMR) for deaths from all causes was significantly higher than expected when compared to statewide levels, while the urban SMR was significantly lower (p less than 0.01). Of the 13 leading causes of death, 9 had rural SMRs significantly higher than expected, while only homicide had a significantly greater urban SMR (p less than 0.01). Although much of the rural/urban difference in overall mortality is attributed to the fact that the rural population is older, figures adjusted for age and race still reveal that the rural death rate is significantly higher than the urban rate (p less than 0.01). Furthermore, there are several specific differences when analyzed by cause of death, age, and race that remain unexplained. Specific rural health problems include congenital anomalies, motor vehicle and other accidents, heart disease, and cerebrovascular disease. Specific urban health problems include homicides and cancer. In addition to metropolitan status, a second indicator of ruralness, county population size, was used to analyze the data and produced similar results. As county population size increases, the total mortality decreases.

Peripheral neuropathy due to perhexilene maleate.

Observations are presented on 3 patients, including one autopsy report, with peripheral neuropathy due to perhexilene maleate (Pexid). Clinically and biochemically perhexilene neuropathy presents features unusual for a drug-induced neuropathy. Patients liable to develop neuropathy can be recognised from clinical criteria or by the use of routine electrophysiological determinations of nerve conduction velocities. At this stage the neuropathy is readily reversible if perhexilene therapy is discontinued. We have sought to examine the problems entailed in the future safety of perhexilene and allied drugs.

The oblique effect in orientation acuity.

We have examined the dependence of rotational acuity on the orientation bandwidth of a stimulus using two-dimensional, band-pass filtered, spatial noise. Stimuli had a bandwidth of 0.5 octave of spatial frequency, centred at 5.0 cyc/deg, and an orientation bandwidth that covered the range from 0.0 to 25.0 deg. Thresholds were obtained on one principal (vertical), and one oblique axis (45 deg). It was found that acuity declined on both axes as bandwidth increased, in a manner that was compatible with simple statistical principles with virtually perfect sampling of the image. There was some evidence that the intrinsic noise is greater on the oblique axis than on the vertical, and that oblique axes are less densely sampled than the principal axes. These differences are small and are insufficient, either on their own or taken together to explain the oblique effect.

Utilisation of transluminal extraction atherectomy in the treatment of saphenous vein graft disease: two case reports.

Saphenous vein graft disease is an increasing problem as more patients undergo bypass grafting and to date the most effective management strategy remains undefined. The major limitations of angioplasty for saphenous vein graft lesions are the risk of distal embolization and restenosis. Primary stenting in this situation results in superior lumen enlargement and higher procedural success but is still associated with significant restenosis. We describe two cases in which transluminal extraction (TEC) atherectomy is utilised for the treatment of vein graft disease with good immediate and long term angiographic results. The first case reports the use of TEC atherectomy for the primary treatment of a discrete eccentric filling defect, and the second case describes the use of this technique in the management of in-stent restenosis.

Vulnerability to noise-induced hearing loss in 'middle-aged' and young adult mice: a dose-response approach in CBA, C57BL, and BALB inbred strains.

Vulnerability of the cochlea to noise-induced permanent threshold shifts (NIPTS) was examined in young adult (1-2 months) and 'middle-aged' (5-7 months) CBA/CaJ, C57BL/6J, and BALB/cJ inbred mice. For each age and strain, a dose-response paradigm was applied, whereby groups of up to 12 animals were exposed to intense broadband noise (110 dB SPL) for varying durations. Exposure durations reliably associated with <10% and >90% probability of a criterion amount of NIPTS (determined 2 weeks post-exposure) were identified, and the minimum NIPTS exposure and the slope of the dose-response relation were then derived by numerical modeling. For all three strains, young adult mice were more susceptible to NIPTS than older adults; That is, a shorter exposure was able to cause NIPTS in the younger mice. Strain comparisons revealed that C57 mice were more susceptible than CBAs in the older age group only. At both ages examined, however, BALB mice were most susceptible to NIPTS. When animals with a similar amount of NIPTS were compared, outer hair cell loss in the cochlear base was more widespread in the younger animals. BALB mice appear particularly susceptible to noise-induced outer hair cell loss throughout life. Our data suggest that the mechanism or site of noise injury differs between young adults and older adults, and may depend on genetic background. The finding that both BALB and C57 mice, which show pronounced age-related hearing loss, are also especially vulnerable to noise supports the notion that genes associated with age-related hearing loss often act by rendering the cochlea susceptible to insults.

The rural-urban distribution of health professionals in Georgia.

In this paper, the rural/urban geographic distribution of licensed health professionals living in the state of Georgia is examined. Using 1983 data from the State Examining Boards, 13 health professions were studied to determine rural and urban differences. Three indicators of ruralness were used to classify county of residence: metropolitan/nonmetropolitan, metropolitan proximity, and size of county population. Results from data analyses indicate a severe geographic maldistribution of health professionals. With all three indicators, 11 of the 13 professions had urban rates of professionals-to-population substantially higher than the corresponding rural rates. A linear configuration seems to illustrate the relationship between the availability of health professionals and the ruralness of the county--as the county becomes more rural, the number of health professionals per population decreases. The percentage increase in physicians since 1968 and nurses since 1979 in nonmetropolitan counties was slightly higher than in metropolitan counties, indicating that this gap is closing somewhat. The most severe rural/urban differences in the number of professionals which per population were found in the more specialized health professions per tended to be the smallest in terms of numbers of members (e.g., occupational therapists, psychologists, speech pathologists/audiologists, podiatrists, opticians and physical therapists). These differences ranged up to a 20 plus-fold difference. Physicians, chiropractors, dentists, physician assistants and registered nurses also had relatively large rural/urban differences but less than the more specialized professions.

Left ventricular aneurysm surgery. Determinants of results.

Between 1967 and 1983, 154 patients had reduction of left ventricular aneurysms by resection or plication. Seventy percent of patients had predominant angina; the remainder had predominant dyspnoea. Fifty-eight percent had associated coronary bypass grafting. Within the group, there were included 26 patients who had aneurysm resection for dyspnoea and who were evaluated by radionuclide angiography at a mean follow-up of 17 + 11 months. There was a 20% early mortality; this fell to 5% in the latter half of this experience. Patients whose major symptom was angina had a 5% early mortality. Those whose major symptom was severe dyspnoea had an early mortality of 30%. Patients who had aneurysm reduction alone had an early mortality of 17% and those who had associated bypass grafting had an early mortality of 9%. There was a 48% late mortality, attrition occurring at a steady rate and being predominantly due to cardiovascular causes. Of 95 patients available for review between one and thirteen years after operation, 60% were in New York Heart Association (N.Y.H.A.) functional class I, 36% in functional class II and 4% in classes III and IV. In patients whose predominant symptom was dyspnoea, radionuclide studies showed that global left ventricular performance at rest was not significantly changed by operation, despite clinical improvement. Long-term clinical outcome was determined more by pre-operative global ventricular function than by function of the residual contractile segment. Within the whole group, however, both early mortality and symptomatic improvement were more likely in patients with predominant angina.