Human lateralization from head to foot: sex-related factors.

Sex differences in the pattern and maturation of lateral asymmetries of the human brain have been recently found by a number of investigators, suggesting that sex-related factors may differentially affect the two sides of the body. In this study, asymmetries in the size of the two feet were strongly related to sex and handedness, right-handed males having larger right feet and right-handed females having larger left feet, the reverse being seen in non-right-handed individuals. Since these differences were apparent even in children younger than 6 years, the fetal sex steroids may be critical in governing the maturation of both cerebral and pedal asymmetries.

[Ductal carcinoma in situ: role of the boost]. / Radiothérapie des carcinomes canalaires in situ: impact du complément d'irradiation du lit tumoral.

Ductal carcinoma in situ is defined as breast cancer confined to the ducts of the breast without evidence of penetration of the basement membrane. Local treatment quality represents one of the most prognostic factors as half of recurrences are invasive diseases. The main goal of adjuvant radiotherapy after conservative surgery is to decrease local recurrences and to permit breast conservation with low treatment-induced sequelae. Several randomized trials have established the impact of 50 Gy to the whole breast in terms of local control. Nevertheless, no randomized trial is still available concerning the role of the boost in this disease. In this review, we present updated results of the literature and we detail the French multicentric randomized trial evaluating the impact of a 16 Gy boost after 50 Gy delivered to the whole breast in 25 fractions and 33 days. This protocol will start inclusions in October 2008.

Effect of vincristine on sister chromatid exchanges of normal human lymphocytes.

In vitro analysis of the mitosis from 3-day lymphocyte cultures from two normal males and two normal females treated with bromodeoxyuridine and stained with acridine orange after addition of vincristine during different times demonstrated that vincristine inhibits the progression of the second division. When the second division progressed, the number of sister chromatid exchanges was significantly decreased. Vincristine could act by inhibiting the copying of DNA. A dosage effect is demonstrated when vincristine is added to the cultures during the first 24 hr.

Phlebotomy with iron therapy to correct the microcytic polycythemia of chronic hypoxia.

Patients with chronic hypoxia develop a physiologically appropriate "secondary" polycythemia that improves oxygen carrying capacity. Supplemental iron is often required to maintain this. In severe cases when hematocrit levels approach 70%, iron is withheld in order to avoid dangerously high hematocrit levels and the risks of vascular sludging due to "hyperviscosity." Some patients even require reduction of viscosity by exchange of their polycythemic blood for plasma when symptoms develop. Iron deficiency with microcytic polycythemia can then develop. Management of such patients is unclear. Continued blood withdrawal will worsen the iron deficiency; iron supplementation will increase the hematocrit level and the risks of hyperviscosity. The combination of frequent phlebotomy with oral iron therapy should improve iron stores while safely maintaining a stable hematocrit level in patients with microcytic polycythemia. This combination should also have multiple beneficial effects on tissue oxygen delivery and utilization. This approach has been discussed and used for a patient with microcytic polycythemia due to Eisenmenger syndrome. While on therapy the patient's clinical symptoms decreased, and his serum iron level, hematologic indices, and treadmill tolerance tests all improved.

Intermediate-term follow-up results of balloon aortic valvuloplasty in infants and children with special reference to causes of restenosis.

Sixteen infants and children with valvular aortic stenosis underwent percutaneous balloon aortic valvuloplasty over a 36-month period ending August 1988. The mean systolic pressure gradient across the aortic valve decreased from 72 +/- 21 (mean +/- standard deviation) to 28 +/- 13 mm Hg (p less than 0.001) immediately after valvuloplasty; the degree of aortic insufficiency did not significantly increase. Follow-up catheterization (in 10 patients) and Doppler data (in all 16 patients) were available 3 to 32 months (mean 12 months) after valvuloplasty and revealed a residual aortic valvular gradient of 37 +/- 23 mm Hg, which continues to be significantly lower (p less than 0.001) than that before valvuloplasty. There was no increase in aortic insufficiency. On the basis of follow-up data, the 16 children were divided into 2 groups: group I with good results (gradients less than or equal to 49 mm Hg), 12 patients; and group II with poor results (gradients greater than or equal to 50 mm Hg), 4 patients. All 4 patients in group II required repeat balloon valvuloplasty or surgical valvotomy; none from group I required these procedures. Seventeen general, anatomic, physiologic and technical variables were examined by a multivariate logistic regression analysis to identify factors associated with restenosis; these risk factors were: age less than or equal to 3 years; and immediate aortic valvular gradient after valvuloplasty greater than or equal to 30 mm Hg. The immediate and intermediate-term follow-up results of balloon aortic valvuloplasty are encouraging. Recognition of the risk factors may help identify potential candidates for recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortico-left ventricular tunnel: diagnosis based on two-dimensional echocardiography, color flow Doppler imaging, and magnetic resonance imaging.

Aortico-left ventricular tunnel is a rare congenital cardiac lesion that often results in severe aortic insufficiency in infancy. In previously reported cases, the diagnosis has often been missed initially despite use of cardiac catheterization and angiography. We describe a patient who underwent successful surgical correction of this malformation at 10 months of age after the diagnosis had been established by use of two-dimensional echocardiography, color flow Doppler imaging, and magnetic resonance imaging. Aortico-left ventricular tunnel can be diagnosed by use of these noninvasive means without cardiac catheterization.

Radionuclide scintiphotography in defining postoperative pulmonary vasoconstriction. Succesful results after tolazoline administration in a four-month-old infant with congenital heart disease.

99mTechnetium macroaggregated albumin has successfully been used to define severe postoperative pulmonary vasoconstriction in a four-month-old boy with D-transposition of the great vessels who had undergone a Blalock-Hanlon surgical atrial septectomy. Radionuclide imaging documented clinically suspected pulmonary vasoconstriction and led to the successful use of tolazoline (Priscoline) to reverse the vasoconstriction with improved pulmonary blood flow patterns.

Presplenectomy transcatheter occlusion of the splenic artery.

Transcatheter splenic artery occlusion can be performed rapidly and safely prior to splenectomy. This procedure reduces splenic bulk and decreases intraoperative bleeding. Patients not operated on after transcatheter splenic artery occlusion have had high mortality, and therefore the procedure should probably not be considered unless splenectomy is contemplated. An illustrative case is reported.

A better surgical technique for repairing pulmonary arteries after banding.

A technique is presented to eliminate the residual gradient more completely after removing the main pulmonary band at the time of primary repair of ventricular septal defect. The band and underlying pulmonary artery are circumferentially excised, except for a small posterior part, and pulmonary artery is reanastomosed.

Intrapulmonary steal complicating repair of tetralogy of Fallot.

A patient with total occlusion of the distal right pulmonary artery secondary to the performance of a Waterston shunt is reported. A nearly fatal intrapulmonary steal occurred at the time of corrective operation when an attempt was made to revascularize both pulmonary arteries.

The Blalock-Taussig operation: the procedure of choice in the hypoxic infant with tetralogy of Fallot.

From 1971 to 1975, 17 consecutive patients aged 1 day to 4 years underwent Blalock-Taussig shunts for severe tetralogy of Fallot. Three infants were under 6 weeks of age and 7 (41%) under 1 year. There were no hospital deaths. Modification of the shunt technique adapts it to any size infant. The subclavian artery is divided at its major branches and the end spatulated to enlarge it. The artery is occluded while the shunt is constructed. No intraoperative complications were encountered; all patients have a shunt murmur with no early or late closure. No child has had heart failure or hypoxic spells. Flows measured at operation equaled one-quarter to one-half of the child's normal cardiac output. Ligation of the shunt at subsequent repair is uncomplicated. One child died three years later at correction from causes unrelated to the shunt. With appropriate modifications in technique, the Blalock-Taussig shunt is the operation of choice, at any age, for palliation of severe tetralogy of Fallot.

Osteocartilaginous tumors in the parapharyngeal space arising from bone exostoses.

Three osteocartilaginous tumors that arose from bone stalks were diagnosed by the demonstration, on multiplanar cross-sectional CT and MR images, of the site of stalk attachment to the adjacent mandible (one), skull base (one), and cervical vertebra (one). All three patients presented with signs and symptoms related to mass effect in the parapharyngeal region. Mass effect was more pronounced in the two cases of malignant degeneration (osteosarcoma, chondrosarcoma) than in the single case of benign osteocartilaginous exostosis. Differentiation of benign from malignant osteocartilaginous tumor may be accomplished by appreciating characteristic CT and MR features of the cartilage cap. The differential diagnosis of mass lesions of the parapharyngeal space should include tumors of osteocartilaginous origin.

Digital subtraction angiography in the community hospital.

Although digital angiography may involve the same physician processes in the university as in the community hospital, it can be seen that the indications, approaches, and utility of DSA are somewhat different in the two environments. DSA is presently in a state of change, in part because of the maturing of other modalities and also because of the present emphasis on cost-saving in medical imaging. As referring physicians become used to digital arteriographic images, more and more procedures will be performed with DSA. We believe the DSA will have an important role in the community hospital for years to come. Its emergence as the first of the "conventional" imaging techniques to be digitized can be seen as an initial step toward the total digital imaging department of the future.

Tuberculoma presenting as an en plaque meningioma. Case report.

Intracranial tuberculomas generally present as either solitary or multiple lesions in the brain parenchyma. They are characterized by a ring-enhancing area on either computerized tomography scans or magnetic resonance images. A case is presented in which an intracranial tuberculoma was dural based and had an appearance similar to an en plaque meningioma.

Childbirth as crisis: a test of Janis's theory of communication and stress resolution.

The relationship between expectation and subjective outcome in childbirth was investigated. Sixty primigravidae responded to a questionnaire before and after labor and delivery. The evaluation of childbirth as favorable or unfavorable was related to whether the experience was rated better or worse than expectation. Anticipation of labor and delivery was positively related to a woman's perception of her mother's experience in childbirth, but was not related to the woman's evaluation of her actual delivery experience. Women receiving extreme communications or no information from their mother reported poorer outcomes than women who received moderate communications. Anxiety, as measured by the Taylor Manifest Anxiety Scale, and denial, as measured by the Self-Criticism Scale of the Tennessee Self-Concept Scale, were not related to anticipation or subjective outcome measures. Results were interpreted within Janis's theory of psychological stress.

Favorable selection in the Medicare+Choice program: new evidence.

Historically, studying the Medicare managed care favorable-selection issue has been difficult because direct data on managed care enrollees have been unavailable. In this study, we analyzed the first year of Balanced Budget Act (BBA)-mandated inpatient encounter data. Based on this comparison of actual managed care and fee-for-service (FFS) beneficiaries, it appears that there are significant differences between these populations. The most striking differences are found in the comparison of average risk factors, indicating a clear bias in the managed care populations toward beneficiaries predicted to be less costly.

The Medicare Fee Schedule unveiled: an account of physician payment reform.

On January 1, 1992, the Medicare program unveiled a new method for paying physicians known as the Medicare Fee Schedule (MFS). The new fee schedule is a complex system of administrative pricing based on the resource inputs used in producing physician services. The MFS consists of three parts: (1) a Relative Value Scale (RVS) which assigns to each medical service a value relative to all other services; (2) a Conversion Factor (CF) which converts the relative values into dollars; and (3) a Geographic Adjustment Factor (GAF) which adjusts payments based on geographic differences in the cost of producing physician services. In the paper we explain: how the relative values were determined; how the GAF was constructed; and how the CF was calculated. In addition, we explain balancing billing limits and the Medicare Volume Performance Standards (MVPS). We then present computer simulations of the impact of the MFS on payments to physicians. We find that the MFS will: (1) redistribute payments away from surgeons, radiologists, and other procedure-based specialties toward the primary care specialties, (2) redistribute payment away from urban areas toward rural areas, (3) redistribute payments away from invasive procedures and diagnostic tests toward evaluation and management services. We conclude with a discussion of the future refinements of the MFS, its applicability to other payors, and whether it will accomplish its intended purposes.

[Neonatal carcinoma. Review of the literature apropos of a case]. / Les carcinomes néonatals. Revue de la litterature a propos d'un cas.

A cortical adrenal carcinoma arising during the neonatal period and associated with virilization recurred after an initial excision and is in complete remission after a follow-up period of 10 years. The authors have performed a review of the medical literature which has yielded 56 neonatal carcinomas including this one. More than half of these cases concerned the thyroid gland (15 cases) and the adrenal cortex (14 cases). These were followed by malignant melanomas (12 cases), carcinomas of the parotid gland (6 cases), oropharyngeal region (3 cases), adrenal medulla (2 cases) and stomach, liver, breast and cutaneous sweat gland (one case each). Six tumors were associated with congenital malformations which included Beckwith-Wiedeman's syndrome; 4 tumors arose from preexisting tissue lesions; in one case, oral contraceptives were taken during pregnancy. The main treatment of neonatal carcinomas is surgery. Local recurrences (7 cases) do not markedly affect the outcome, whereas metastases (12 cases) have a very unfavorable prognosis. Superficial tumors are diagnosed earlier and more frequently cured. Out of 44 cases for which the outcome is known, only 18 children survived.

Risk Adjustment for the Medicare program: lessons learned from research and demonstrations.

The Balanced Budget Act (BBA) of 1997 requires numerous changes in Medicare. Medicare's managed care program has been reinvented as "Medicare + Choice," offering an expanded range of delivery system options for beneficiaries and a schedule of payment changes that will dramatically affect managed care plans. Preceding some of these BBA-legislated changes to Medicare were years of research and demonstrations. Risk-adjusted payment in the Medicare + Choice program, which is mandated for implementation in 2000, is one example of a longstanding developmental initiative. This paper provides a brief overview of risk adjustment-related research and demonstration activities carried out by the Health Care Financing Administration (HCFA) since the 1980s, and describes a possible technical approach for the implementation of risk-adjusted Medicare managed care payments in 2000.