Athetoid and choreiform hyperkinesias produced by caudate lesions in the cat.

Small, unilateral lesions, which damage exclusively the anteroventral region of the caudate nucleus of the cat, produce a stable and permanent behavioral change resembling human athetoid and choreiform hyperkinesias. These symptoms are not seen after generalized destrulction of the caudate nuicleuts.

Videometric analysis of regional left ventricular function before and after aortocoronary artery bypass surgery: correlation of peak rate of myocardial wall thickening with late postoperative graft flows.

The peak rate of systolic wall thickening (pdTw/dt) in regions of the left ventricle was determined by biplane roentgen videometry in 60 patients before and a median of 14 mo after aorto-coronary bypass graft surgery. The left ventricular ejection fraction, stroke volume, and end-diastolic volume and pressure did not change significantly after surgery in the presence of patent or occluded grafts (P greater than 0.05). Statistically significant increases occurred in the peak rate of systolic wall thickening regions supplied by patent bypass grafts, and significant decreases occurred in regions with occluded grafts (P less than 0.01). Of 42 preoperatively hypokinetic regions (pdTw/dt greater than 0 less than 5.0 cm/s) supplied by a patent graft, 30 improved by an average of 2.6 cm/s after operation; 18 returned to normal. Failure of 24 hypokinetic regions to improve to normal was associated with myocardial infarction in 11 or with late postoperative graft blood flows of less than 60 ml/min measured by videodensitometry, in 10. All seven preoperatively akinetic (pdTw/dt=0) or dyskinetic (pdTw/dt less than 0) regions did not improve after the operation despite the fact that, in five of the seven, coronary bypass flows were over 60 ml/min. All eight preoperatively hypokinetic regions supplied by coronary artery graft flows of less than or equal 40 ml/min failed to improve to normal after operation. All nine preoperatively hypokinetic regions supplied by coronary artery graft flows of over 60 ml/min improved to normal after surgery. Late postoperative coronary artery bypass graft flows, the functional status of the myocardium, the status and distribution of the native coronary circulation, and decreased regional function elsewhere in the ventricle must all be considered when regional left ventricular function is interpreted.

Double outlet right ventricle: hemodynamic and anatomic correlations.

There are 16 possible variations of double outlet ventricle with regard to interrelations of the great arteries and to location of the ventricular septal defect. In a series of 62 cases, approximately two thirds of patients had the great arteries in a side by side relation, and most (28 of 41) had the ventricular septal defect in a subaortic position. In double outlet right ventricle with malposition of the great arteries, the ventricular septal defect was either subpulmonary or subaortic. Four of the 13 patients with subpulmonary ventricular septal defect had a supracristal defect with side by side relation of the great arteries (Taussig-Bing anomaly), and 9 patients had malposition of the great arteries with an infracristal ventricular septal defect. In all patients with subpulmonary ventricular septal defect, pulmonary arterial oxygen saturation was greater than systemic arterial saturation regardless of the relation of the great arteries. Forty patients had subaortic ventricular septal defect. In 24 of these patients, including 7 with malposition of the great arteries, systemic arterial oxygen saturation was greater than pulmonary arterial saturation. However, in 9 patients (25 percent) the reverse was true, as seen in complete transposition of the great arteries and in Taussig-Bing anomaly. Thus, pulmonary arterial oxygen saturation greater than systemic arterial saturation is not reliable evidence of a Taussig-Bing anomaly. Of the 25 patients with such saturation, only 4 had the Taussig-Bing anomaly.

Regional left ventricular wall dynamics before and after sublingual administration of nitroglycerin.

Regional wall dynamics of the left ventricle before and after sublingual administration of 0.6 mg of nitroglycerin were determined from left ventricular angiograms in 27 patients undergoing coronary arteriography. Regional wall dynamics were quantitatively measured from 60/sec determinations of wall thickness and derived peak rate of systolic wall thickening (peak dTw/dt) in selected sites of the left ventricle. A total of 70 regions were studied. Analysis of the same segment before and after administration of nitroglycerin revealed that the mean change in peak dTw/dt was +1.97 cm/sec in segments with an initial peak dTw/dt of less than 5 cm/sec, in contrast to a change of +0.66 cm/sec in segments with an initial control value of 5 cm/sec or greater. Akinetic or dyskinetic areas did not show improvements after nitroglycerin. In 11 left ventriculograms, an area that was initially hypokinetic manifested an increase in rate of wall thickening after nitroglycerin. The mean increase in peak dTw/dt in anterior segments with electrocardiographic evidence of myocardial infarction was 0.18 cm/sec (P less than 0.05) after nitroglycerin, compared with a mean change of 1.33 cm/sec in anterior segments without such evidence. This study presents evidence for a regional myocardial response to nitroglycerin with differing responses within the same ventricle apparently depending upon the functional state of the underlying myocardium.

Relation of intraoperative or early postoperative transmural myocardial infarction to patency of aortocoronary bypass grafts and to diseased ungrafted coronary arteries.

Serial preoperative and postoperative electrocardiograms and vectorcardiograms were obtained in 500 patients undergoing saphenous vein aortocoronary artery bypass graft surgery. Evidence of transmural myocardial infarction was found early postoperatively in 67 patients (13 percent). Age and sex distributions, number of vessels diseased or vessels grafted, and preoperative and postoperative New York Heart Association functional classification (mean follow-up, 26 months) did not differ in the groups with and without infarction. Increased duration of cardiopulmonary bypass time (more than 120 minutes) was slightly greater in the group with infarction (P smaller than 0.05). Multivariate analysis revealed that 60 percent of patients in the group with infarction were identified by a 1st day serum glutamic oxaloacetic transaminase value greater than 100 U/liter; however, for each such patient identified, there was approximately one false positive result. Use of other values (creatine phosphokinase, cardiopulmonary bypass time and total anoxic rest time) did not improve discrimination. Twenty-five percent of all transmural infarctions occurred within the zone of myocardium supplied by a diseased ungrafted artery. In 32 patients with early evidence of transmural mycardial infarction in a zone of myocardium supplied by a grafted artery, postoperative angiography showed as many with patent as with occluded grafts. Of 154 patients in the group without infarction who had early postoperative graft angiograms, 30 (19 percent) had one graft occluded and yet no evidence of transmural infarction by our criteria. Therefore, early postoperative evidence of transmural myocardial infarction as defined in this study is an unreliable indicator of the status of the graft supplying the zone of infarction.

Double-outlet right ventricle. Anatomic and angiocardiographic correlations.

A series of 72 patients with proved double-outlet right ventricle was studied with reference to the ability of angiocardiography to determine the location of a ventricular septal defect when it was associated with various great-artery relationships. Only 2 of the 72 patients had an intact ventricular septum. The other 70 patients had 16 possible anatomic variations based on four positions of the ventricular septal defect (subaortic, subpulmonary, subaortic and subpulmonary, and remote type) and four great-artery relationships (normal, side by side, dextromalposition, and levomalposition). Using the hemodynamic information regarding systemic and pulmonary arterial saturations, combined with biplane angiocardiographic data from the right ventricle (and if possible with left ventriculography), one can predict the location of ventricular septal defect. Because the different types of double-outlet right ventricle have different surgical approaches, this information can be important to the surgeon.

Straddling right atrioventricular valve in criss-cross atrioventricular relationship.

Two cases of complex congenital heart disease are described in which systemic and pulmonary bloodstreams crossed at the atrioventricular level. Both patients were examined clinically, echocardiographically, and by cardiac catheterization, including angiography, and both underwent cardiac surgery and had intraoperative mapping of their conduction systems. Both patients were found to have levocardia and situs solitus of viscera and atria, large ventricular septal defect, and straddling right atrioventricular valve. One patient had atrioventricular discordance but with the left ventricle anterior and alightly on the right and with pulmonary atresia and dextromalposition of the aorta. The other patient had atrioventricular concordance but with the left ventricle inferior and slightly on the left and with ventricular-arterial concordance to normally related great arteries and banded pulmonary trunk. To our knowledge, this combination including straddling right atrioventricular valve has not been reported in the literature before. In both patients the straddling atrioventricular valve was thought to preclude corrective operation at that time. A unique palliative procedure--left ventricle-to-pulmonary trunk shunt--was successful in the first case and partial debanding of the pulmonary trunk in the second.

A criss-cross heart. Detailed anatomic description and discussion of morphogenesis.

Hearts with criss-cross atrioventricular connections are rare. Reports in the literature describe great anatomic variations with regard to the atrioventricular connections, spatial relationships of the ventricles, and connections and spatial relationships of the great arteries. In the example described in this report, the basic anatomic picture was that of transposition of the great arteries, but the criss-cross atrioventricular valves had resulted in atrioventricular discordance; hemodynamically, therefore, the situation resembled congenitally corrected transposition. One hypothesis for this anatomic configuration is that pronounced counterclockwise rotation (as viewed from below) brought the ventricular septum into a frontal plane and altered the respective positions of the pulmonary and aortic valves from those usually seen in congenitally corrected transposition and thereby resulted in crossed atrioventricular connections. An alternative hypothesis is that in this case one of the atrioventricular valves (the anteriorly positioned valve) may represent an anomalous communication that developed early in embryogenesis and connected the left atrial appendage to the right ventricular infundibulum.

Aorta-coronary artery saphenous vein bypass surgery: clinical and angiographic results.

In a series of 500 consecutive patients undergoing aorta-coronary artery saphenous vein bypass surgery, operative mortality was 2.5% (1% with one-vessel disease, 2% with two-vessel disease, and 3% with three-vessel disease). Transmural myocardial infarction occurred within 30 days after operation in 67 cases (13%) and caused 10 of the 16 deaths in that period. Among 484 patients followed 1 to 58 months (median, 26 months), there have been 20 deaths. Of the 464 survivors, 65% had complete relief of angina, 24% were improved, and 11% were unimproved. In 162 patients who underwent postoperative graft angiography between 1 and 42 months after surgery, a strong positive relationship existed between clinical response and completeness of myocardial revascularization as defined by the presence of a patent graft to all major coronary arteries with greater than 50% stenosis. A similar relationship was found between postoperative multistage treadmill exercise response and completeness of myocardial revascularization. Thus, 82% of patients completely revascularized were asymptomatic at the time of postoperative graft visualization, and 91% had a negative treadmill exercise response.

Cardiac rhabdomyoma simulating mitral atresia.

Clinical, catheterization, and pathologic findings were recorded in a newborn infant with tuberous sclerosis and multiple cardiac rhabdomyomas that produced a clinical picture simulating mitral atresia and the hypoplastic left-heart syndrome. The clinical picture was due to a left atrial tumor that completely obstructed the mitral valvular orifice. Even if the diagnosis of left atrial tumor had been made, successful surgical correction was unlikely because of left ventricular rhabdomyomas, which produced severe subvalvular aortic stenosis and did not appear to be resectable. This case demonstrates the possibility that a hamartoma, such as a rhabdomyoma, occasionally can mimic the hypoplastic left-heart syndrome.

Management of endometriosis and its associated adhesions with the CO2 laser laparoscope.

One hundred fifty-eight patients with endometriosis were treated with the carbon dioxide laser laparoscope and followed for 15 months. The revised American Fertility Society classification of endometriosis was used to stage the disease. The median revised American Fertility Society points per patient was 29.4. Removal of adhesions, periureteral endometriosis, and superficial bowel endometriosis was accomplished. Complications consisted of bleeding, extravasation of fluid, and uterine and bladder puncture. No serious complications requiring laparotomy were encountered. Significant relief of dysmenorrhea and dyspareunia as well as enhanced fertility was achieved. Second-look laparoscopy confirmed efficient removal of endometriosis. Pain relief and pregnancy data are presented. Endometriosis and its related adhesions can be removed precisely and relatively bloodlessly with the carbon dioxide laser laparoscope. Expertise in advanced laparoscopy and a thorough knowledge of use of the carbon dioxide laser and its bioeffects are prerequisites to performing this procedure.

Management of Bartholin duct cysts with the carbon dioxide laser.

Fourteen women with Bartholin duct cysts were treated by creating a neostoma with the carbon dioxide laser at the time of cyst drainage. No catheters, packs, or other materials were left in the treated gland. All but one patient were treated in the author's office under local anesthesia. All patients were managed using the same operative technique. Twelve of the 14 patients required only one treatment. One patient required three operations and another two procedures. General anesthesia was necessary in only one patient. All patients conformed to long-term follow-up. All patients are now free of disease and apparently have normal glandular function. It is concluded that this technique, when used in selected patients, may offer benefits over conventional approaches and has little or no morbidity.

Excision of pelvic endometriosis with the carbon dioxide laser laparoscope.

Laparoscopic vaporization of peritoneal endometriosis has been reported to relieve pain and enhance fertility. However, vaporization of endometriosis, particularly large plaques and hemorrhagic areas, is associated with significant amounts of carbon deposition in the desicated tissues. Further, it is difficult to ascertain complete removal of disease in some areas. In this study, 66 patients were treated by excision of peritoneal and/or ovarian endometriosis with the carbon dioxide laser via laparoscopy. Using excisional techniques, we were able to visualize the extent of peritoneal penetration and subperitoneal spread of endometriotic nodules. Further, we obtained histologic confirmation of the disease process in all patients. No patient received postoperative hormonal therapy during follow-up. Follow-up evaluation of these patients revealed relief of the painful symptoms of endometriosis. No long-term complications were encountered.

Capillary hemangioma of the cervix and vagina: management with carbon dioxide laser.

A hemangioma involving the cervix and vagina was treated successfully with the carbon dioxide laser. This is the second such instance reported. The world literature has been reviewed, and the operation described in detail. This benign neoplasm can be managed conservatively in young women who desire preservation of their childbearing ability.

A microlaparoscopic technique for Pomeroy tubal ligation.

OBJECTIVE: To evaluate the efficacy of performing Pomeroy tubal ligation using microlaparoscopic techniques. METHODS: Thirty-eight consecutive women desiring permanent sterilization underwent laparoscopic Pomeroy tubal ligation using small (2 or 5 mm) transumbilical laparoscopes and secondary midline sites (5 mm and 14 gauge). The procedures were performed under general anesthesia (n = 28) or local anesthesia with conscious sedation (n = 10). RESULTS: The mean operative time +/- standard deviation (SD) in minutes was 33.0 +/- 10.3. The mean recovery time +/- SD in minutes was 104.3 +/- 41.6. There were no operative complications, and no cases required conversion from the microlaparoscopic technique to a traditional method. CONCLUSION: The results of this study indicate that the Pomeroy tubal ligation may be performed using microlaparoscopic techniques. Furthermore, in selected cases, this technique can be performed under local anesthesia in an outpatient setting.

Credentialing residents for intraoperative cystoscopy.

OBJECTIVE: To determine whether incorporation of routine intraoperative cystoscopy for evaluation of potential urinary tract injury into gynecologic residency training provides sufficient experience to justify hospital credentials after graduation. METHODS: We developed a curriculum to train residents in intraoperative cystoscopic evaluation of potential lower urinary tract injury. Cystoscopy was performed when indicated with hysterectomy and routinely in conjunction with pelvic reconstruction. Faculty members evaluated conceptual and technical proficiency by oral examination and direct observation in the operating room. Once the resident demonstrated a thorough understanding and proficiency in performing intraoperative cystoscopy, a competency certification document was issued by the Program Director. This certification was transmitted to the postresidency hospital credentials committee to justify granting privileges. RESULTS: Since 1994 over 400 transurethral cystoscopic evaluations have been done in conjunction with major gynecologic abdominal and vaginal surgeries, and since 1997 an additional 50 transvesical microcystoscopies have been done in selected abdominal cases. Twenty-five residency graduates have been certified as fully trained in intraoperative diagnostic cystoscopy. All these graduates have been granted intraoperative cystoscopy privileges at their subsequent hospital practice. CONCLUSION: Incorporation of cystoscopic urinary tract evaluation into routine gynecologic surgical training is good medical practice and provided a mechanism whereby obstetrics and gynecology residents could obtain intraoperative cystoscopy hospital privileges after graduation. (Obstet Gynecol 2000;96:1014-7.)

Purification of (+)-delta-cadinene synthase, a sesquiterpene cyclase from bacteria-inoculated cotton foliar tissue.

A sesquiterpene cyclase whose activity is induced in a glandless, bacterial blight-resistant line of cotton (Gossypium hirsutum L.) catalyses the conversion of (E,E)-farnesyl diphosphate to (+)-delta-cadinene. This enzyme was purified by a combination of salt-induced phase separation, hydroxylapatite fractionation, hydrophobic interaction and strong anion-exchange chromatography, and denaturing polyacrylamide gel electrophoresis, followed by renaturation with Tween 80. The purified enzyme has a molecular weight of 64-65 kDa, and exhibited a single silver-staining band following electrophoresis in analytical denaturing polyacrylamide gels. Amino acid sequences of three tryptic peptides from the enzyme have been determined and are similar to known sequences in other terpene cyclases from plants.

Abnormal eating behaviors in military women.

PURPOSE: The purpose of this study was to evaluate the prevalence of abnormal eating behaviors in women on active duty in the Army. METHODS: A total of 423 female soldiers from the general population on active duty volunteered to participate in this study. They completed the Eating Disorder Inventory (EDI) questionnaire. Each questionnaire was screened and any woman on active duty practicing abnormal eating behaviors (criteria set up by the authors) underwent an interview. A diagnosis, using DSM IV criteria, of one of the following was determined from the interview: 1) No eating disorder, (2) Anorexia nervosa, 3) Bulimia nervosa, 4) binge eating disorder, 5a) Eating disorder NOS, and 5b) Situational eating disorder. A situational eating disorder was defined as any abnormal eating behaviors consistent with an eating disorder NOS that was practiced intermittently and in response to external pressures associated with significant distress, such as military weigh-ins or army physical fitness testing (APFT). RESULTS: Of the 423 women on active duty who participated, 33.6% (N = 142) met the questionnaire screening criteria for being "at risk" for abnormal eating behaviors and underwent an interview. Of the 142 women interviewed, 33 (8%) women were diagnosed with an eating disorder. The women with eating disorders exercised, felt dissatisfied with their weight, and felt significantly more pressure about their weight than the women without eating disorders. In addition, they also had significantly greater scores on the Drive for Thinness (DT), Bulemia (B), and Body Dissatisfaction (BD) subscales, and the total EDI scores for both the 8 and 11 subscales. CONCLUSION: In the women on active duty in the Army studied, there was an 8% prevalence of eating disorders.

Clinical characteristics of adolescent endometriosis.

Our study objective was to describe the appearance, stage, and treatment of endometriosis in adolescents undergoing laparoscopic treatment of severe dysmenorrhea and endometriosis. We designed a retrospective analysis of adolescents with endometriosis whose primary symptom was severe dysmenorrhea. We studied patients in a private practice associated with a residency program. Forty-nine adolescents with histologically confirmed endometriosis underwent laparoscopy. Thirty-six of these patients (mean age, 16.6 +/- 1.4 years; range, 13-20 years) presented with severe dysmenorrhea in a non-emergency state and were refractory to prior therapy. All patients underwent laparoscopic surgery. We classified endometriosis implants as typical implants, red lesions, and occult lesions in thirty-six adolescents. We excised infiltrating lesions (defined as implants penetrating greater than 3-5 mm) and vaporized or coagulated superficial lesions (defined as surface implants or those penetrating < 3 mm). All adolescents underwent postsurgical ovulation suppression with a daily birth control pill. The need for reoperation at any time or the use of GnRH analogs, Danazol, or large doses of progestins served to indicate treatment failure. The presence or absence of red lesions was recorded in this group and compared to the presence or absence of such lesions in an older population of patients undergoing definitive therapy for endometriosis during the same time period. Our results showed that red lesions are the predominant implant type in adolescents. Adolescents with cyclic pain and those who complain of abdominal pain, nausea, constipation, and diarrhea, during menses had the largest proportion of red lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

Colposcopic examination of the vagina.

Examination of the vagina must include assessment of the minor vestibular glands and urethral meatus. Vaginal mucosal lesions related to papillomavirus infection and neoplasia are best discovered by the use of acetic acid wash followed by the application of Monsel's solution.