Evaluation of mitral leaflet motion by echocardiography and jet direction by Doppler color flow mapping to determine the mechanisms of mitral regurgitation.

OBJECTIVES: This study was designed to assess the accuracy of two-dimensional and Doppler echocardiography in determining the mechanism of mitral regurgitation, as compared with direct inspection of the valve at operation. BACKGROUND: Valve repair for mitral regurgitation offers substantial advantages over valve replacement, but it is technically more demanding and requires understanding of the mechanism of dysfunction. METHODS: We studied 286 patients undergoing mitral valve repair. Intraoperative two-dimensional echocardiography was used to classify mitral leaflet motion as excessive, normal or restricted. Doppler color flow mapping was used to evaluate the direction and origin of the mitral regurgitant jet. Two-dimensional and Doppler echocardiography were compared with intraoperative surgical determination of the mechanism of dysfunction, which also classified leaflet motion as excessive, normal or restricted. RESULTS: Two-dimensional and Doppler echocardiography accurately diagnosed the mechanism of mitral regurgitation in 123 (93%) of 132 patients with posterior leaflet prolapse or flail, 30 (94%) of 32 patients with anterior leaflet prolapse or flail, 11 (44%) of 25 patients with bileaflet prolapse or flail, 6 (75%) of 8 patients with papillary muscle elongation or rupture, 31 (91%) of 34 patients with restricted leaflet motion or rheumatic thickening, 21 (72%) of 29 patients with ventricular-annular dilation and 8 (62%) of 13 patients with a leaflet perforation or cleft. Of 13 patients with two mechanisms of dysfunction by surgical inspection, two-dimensional and Doppler echocardiography correctly diagnosed one of the two mechanisms in 12 patients (92%), and both mechanisms in 5 patients (38%). Overall, echocardiographic determination of leaflet motion and Doppler determination of jet direction accurately diagnosed the mechanism of dysfunction in 242 (85%) of 286 patients. CONCLUSIONS: Echocardiography before mitral valvuloplasty provides a dynamic appraisal of the mechanism of dysfunction, enabling the surgeon to systematically understand the dysfunction and successfully apply the correct procedures to eliminate mitral regurgitation without valve replacement.

Impact of tissue harmonic imaging on the assessment of rheumatic mitral stenosis.

We examined the effect of tissue harmonic imaging on the echocardiographic splitability score and valve area measurement of 40 patients with rheumatic mitral stenosis. Planimetered valve areas were unaffected by the use of harmonic imaging, but valve scores were increased, particularly in patients with scores <10.

Transthoracic echocardiography documents prompt resolution of right atrial thrombus after thrombolytic therapy.

Right atrial thrombi represent pulmonary emboli in transit, and they may be fatal in patients treated conservatively with anticoagulation. This case provides an opportunity to review echocardiographic findings and management decisions in this disease entity. As the literature now favors thrombolytic therapy in suitable patients, we present a case in which transthoracic echocardiography provided rapid assessment of the outcome of this form of therapy.

Intraoperative transesophageal echocardiographic localization of tumor embolus during pneumonectomy.

We describe a patient undergoing pneumonectomy for large-cell carcinoma, which at the time of surgery was found to invade the pulmonary veins. Transesophageal echocardiography was used to confirm and localize suspected tumor embolization during surgery. Although tumor embolization from the pulmonary veins has been previously reported in the literature, this is the first case, to our knowledge, of transesophageal echocardiographic documentation of such an occurrence. The use of echocardiography in patients at potential risk for tumor involvement of the pulmonary veins is discussed.

Sensitization of the visual field.

Three experiments investigated the identification or localization of a letter that was displaced from the fixation point by 1 degree-3 degrees. The subject's task was to identify a fixated letter and identify (Experiment 1) or localize (Experiments 2 and 3) the displaced letter. On uncued trials, the displaced letter could appear at any of eight locations on any of three rings surrounding the fixated letter; on cued trials, the ring containing the displaced letter was specified. The results indicated that cuing improved subjects' identification and localization of the displaced letter. Invalid cuing (Experiment 3) produced costs comparable in magnitude to the benefits. The distance of the target from the cued ring determined cost, but costs were unaffected by the appearance of a target within the presumed beam of attention. It was proposed that attention should be viewed as a general, rather than feature-specific, resource that can be voluntarily allocated to multiple regions of the visual field.

Reallocation of visual attention.

Attentional movement time was investigated within and across hemifields in a discrimination task in which retinal acuity was controlled. Ss discriminated targets in a two-alternative, forced-choice latency paradigm. In Experiments 1-3, costs were mediated by distance, even though it was varied independently of acuity. In Experiments 4 and 7, with distance held constant, costs were equivalent for crossing the vertical and horizontal meridians and for crossing 1 and 2 meridians. However, crossing 1 meridian produced costs that were less than the costs for shifts to unexpected locations in the same quadrant, partially replicating the inhibitory aftereffect of Tassinari, Aglioti,Chelazzi,Marzi,and Berlucchi (1987). An explanation based on a combination of analog movement (Tsal, 1983) and attentional distribution (Downing & Pinker, 1985; Hughes & Zimba, 1987; Tassinari et al., 1987) models was discussed.

Effectiveness of nicotine patches in a workplace smoking cessation program. An eleven-month follow-up study.

Transdermal nicotine patches are widely prescribed as part of smoking cessation programs, but their efficacy beyond 6 months is not well established. We evaluated the efficacy of a 70-day treatment regimen among 75 subjects in an industrial setting where follow-up was conducted for 11 months. The median time free of cigarettes was 73 days, and the overall smoking abstinence rate was 9% after 11 months of follow-up. Smoking abstinence was significantly higher among those subjects who completed the full course of treatment than among those who did not (25 vs 6%, respectively). Smoking abstinence was also higher among subjects who started smoking after age 17 than among those who started at younger ages and was higher among male than female subjects. We conclude that transdermal nicotine patches are of limited efficacy in achieving long-term smoking cessation and that the relative costs and benefits of this treatment are not adequately specified.

Wood-dust exposures and cancer of the colon.

Previous studies of workers exposed to wood dusts have shown a decreased risk of cancer of the colon in these workers. However, none of these studies adequately controlled for potential confounders, such as physical activity, diet, and family history of colorectal cancer. The purpose of this case-control study was to evaluate the association between exposure to wood dust and risk for colon cancer after adjusting for potential confounders. Four hundred nineteen male cases of adenocarcinoma of the colon, identified from the Los Angeles County Cancer Surveillance Program, were individually matched to neighborhood controls based on gender and date of birth. Exposure to wood dust was associated with reduced risk of colon cancer that was partially masked before adjustment for confounders, and was limited to workers with frequent exposures that had begun at least 30 years before diagnosis [unadjusted and adjusted ORs, respectively, to exposures 5+ times a week beginning 30+ years before diagnosis = 0.63 (95% CI 0.36-1.13) and 0.39 (95% CI 0.20-0.77)]. This study provides additional evidence that heavy exposure to wood dusts may be associated with reduced risk of colon cancer in males after adjustment for other known causes of colon cancer.

Transesophageal echocardiography: first-line imaging for aortic diseases.

Transesophageal echocardiography (TEE) is now commonly used to evaluate the thoracic aorta, because it is widely available and provides high-resolution images and flow information by Doppler. This article reviews the essential features on TEE of acute and chronic aortic diseases, such as aortic dissection, aneurysm, and atherosclerosis, and discusses its strengths, weaknesses, and indications.

Integration of nonthematic details in pictures and passages.

Nonthematic details in naturalistic scenes were manipulated to produce four stimulus versions: color photos, black-white copies, and elaborated and unelaborated line drawings (Experiment 1); analogous verbal descriptions of each visual version were produced for Experiment 2. In Experiment 1, two or three different versions of a scene were presented in the mixed condition; the same version of the scene was repeated either two or three times in the same condition, and a 1-presentation control condition was also included. In Experiment 2, the same presentation conditions were used across different groups of subjects who either viewed the pictures or heard the descriptions. An old/new recognition test was given in which the nonstudied versions of the studied items were used as foils. Higher false recognition performances for the mixed condition were found for the visual materials in both experiments, and in the second experiment the verbal materials produced equivalently high levels of false recognition for both same and mixed conditions. Additionally, in Experiment 2 the patterns of performances across material conditions were differentially affected by the manipulation of detail in the four stimulus versions. These differences across materials suggest that the integration of semantically consistent details across temporally separable presentations is facilitated when the stimuli do not provide visual/physical attributes to enhance discrimination of different presentations. Further, the evidence derived from the visual scenes in both experiments indicates that the semantic schema abstracted from a picture is not the sole mediator of recognition performance.

Transmission-based precautions and anesthesia care.

This column will give a brief history of the development of guidelines for isolation precautions in hospitals. The current Centers for Disease Control and Prevention (CDC) guidelines will be reviewed along with examples of the disease processes that apply to each category. An example of an anesthesia department's guide for the care of patients with transmissible diseases requiring anesthesia care will be presented. The guide can be used by readers as a template for the development of a guide applicable to their practice.

Synthesis, cytotoxicity, and hydroxyapatite formation in 27-Tris-SBF for sol-gel based CaO-P2O5-SiO2-B2O3-ZnO bioactive glasses.

CaO-P2O5-SiO2-B2O3-ZnO bioactive glasses were prepared via an optimized sol-gel method. The current investigation was focused on producing novel zinc based calcium phosphoborosilicate glasses and to evaluate their mechanical, rheological, and biocompatible properties. The morphology and composition of these glasses were studied using X-ray diffraction (XRD) and scanning electron microscopy (SEM). The particle size, mechanical and flexural strength was also determined. Furthermore, the zeta potential of all the glasses were determined to estimate their flocculation tendency. The thermal analysis and weight loss measurements were carried out using differential scanning calorimetry (DSC) and thermogravimetric analysis (TGA) respectively. For assessing the in-vitro bioactive character of synthesized glasses, the ability for apatite formation on their surface upon their immersion in simulated body fluid (SBF) was checked using SEM and pH measurements. MTS assay cytotoxicity assay and live-dead cell viability test were conducted on J774A.1 cells murine macrophage cells for different glass concentrations.

Organization and long-term memory search.

A recognition RT paradigm was used to assess a number of plausible search strategies in LTM for categorized lists. List length was determined by factorially combining two, three, or five categories with two, three, or five words per category, and test items could be one of four types: (1) positive, (2) a repeated positive, (3) a related negative, or (4) an unrelated negative. It was found that RT increased linearly with category size for both positive and related negatives (about 30-40 msec/item); whereas the increase was much smaller for the unrelated negatives, especially for three and five categories (about 9 msec/item). With an increase in the number of categories, RT increased at the rate of about 40 msec/category for all three test items. A theory of .high-speed scanning for categorized material was proposed in which a serial and exhaustive search of the categories, is first undertaken. If a positive category match is found, a serial and exhaustive search within the contents of the positive category is initiated; if no category match is found, the search is simply terminated. Some evidence was presented that categories recently probed may provide for a short-circuiting of the category search.

Triadic decision making in lexical memory.

Word and category recognition was investigated in the context of other stimuli, where the semantic distance relationships among the stimuli were derived from multidimensional scaling. On each trial, three horizontal strings of letters were presented. In the word condition, a positive response was required when the three strings formed three words; in the category condition, a positive response was required when the three strings formed words belonging to the same category. The results indicated that: (a) category decisions take about 150-200 msec longer than do word decisions, (b) word decisions are facilitated by a common categorical membership but semantic distances within the category are relatively unimportant, and (c)within-category semantic distances systematically altered response time for the category condition. It was hypothesized that semantic distance relationships may be sensitized for categorical decisions, but that only large semantic distances function effectively for word decisions.

Perceptual selectivity and the fate of unemphasized information in a stimulus complex.

The potential role of selectivity in visual perception was investigated for stimuli containing multiple components. Primary interest centered on the role of prior emphasis on the perceptual processing of one component, relative to the perceptual fate of the remaining components in the stimulus, and whether unemphasized components fared less well than those same components on an uninstructed trial. On each trial, a face, scrambled face, or single-component stimulus was briefly presented, followed by a patterned mask and a forced choice test of each of the components teye, nose, mouth). On a cued trial, the subject was instructed to emphasize one component, although all three components were subsequently tested; on an uncued trial, no prior instructions were given. The results indicated that identification of an emphasized stimulus component was enhanced, but only at the detriment of the remaining components; that is, components were perceived more accurately on an uncued trial than unemphasized components on a cued trial. Although face and scrambled face stimuli were perceived unequally, the effectiveness of prior instructions was equivalent. Surprisingly, the overall identifiability of the components within a stimulus was independent of prior instructions, and suggested that a finite capacity is available for perceptual analysis.

Expanding the search for a linear separability constraint on category learning.

Formal models of categorization make different predictions about the theoretical importance of linear separability. Prior research, most of which has failed to find support for a linear separability constraint on category learning, has been conducted using tasks that involve learning two categories with a small number of members. The present experiment used four categories with three or nine patterns per category that were either linearly separable or not linearly separable. With overall category structure equivalent across category types, the linearly separable categories were found to be easier to learn than the not linearly separable categories. An analysis of individual participants' data showed that there were more participants operating under a linear separability constraint when learning large categories than when learning small ones. Formal modeling showed that an exemplar model could not account for many of these data. These results are taken to support the existence of multiple processes in categorization.

Infectious diseases in the operating room.

Patients with infectious diseases have special implications for infection control in the operating room. The increased use and abuse of antibiotics has ushered in a category of resistant organisms. These multiresistant organisms are spread by direct or indirect contact, primarily from the hands of caregivers or contact with contaminated environmental surfaces. Another category of infectious diseases is prions (pronounced pree-ons). Unlike other infectious diseases, human prions diseases are not spread through routine exposures such as direct contact, droplet, and airborne routes. The causative agent is highly resistant to traditional disinfecting and sterilization processes. This article provides an overview of the multiresistant infections of methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and Staphylococcus aureus with reduced susceptibility to vancomycin along with the human prions diseases Creutzfeldt-Jakob disease, German-Straüssler-Scheinker syndrome, kuru, and fatal familial insomnia. We provide a template of precautions that can be used in developing operating room and anesthesia infection control protocols for this patient population.