Three-dimensional sonography of the posterior fossa in fetuses with open spina bifida at 11-13 weeks' gestation.

OBJECTIVES: To investigate the posterior fossa of normal fetuses and fetuses with open spina bifida in stored three-dimensional (3D) volumes and to describe signs that might allow early detection of this defect. METHODS: A prospective study of 3D volumes of the fetal brain obtained from 10 normal fetuses and three fetuses with open spina bifida was undertaken. Measurements of the anteroposterior diameters of the cisterna magna and fourth ventricle were taken in the tilted axial view. In the mid-sagittal plane the brainstem (BS) diameter and the brainstem-occipital bone (BSOB) distance were measured. The BS/BSOB ratio was calculated. All measurements were expressed as Z-scores. Structural analysis of the differences in the posterior fossa between normal fetuses and fetuses with open spina bifida was undertaken. RESULTS: In normal fetuses all measurements were within ±2.5 Z-scores. In three fetuses with open spina bifida the BS Z-scores were 2.7, 2.8 and 2.8; the BSOB scores were -3.4, -2.8 and -2.9; the cisterna magna scores were -5.6, -3.7 and -4.2; and the BS/BSOB ratio scores were 4.1, 9.7 and 8.9. In normal fetuses the cisterna magna was posterior to the fourth ventricle and extended along its entire length. In fetuses with open spina bifida the cisterna magna was partially or completely obliterated. CONCLUSIONS: Assessment of the cranial posterior fossa is feasible at 11-13 weeks' gestation. There are distinct signs in fetuses with open spina bifida which can be evaluated by ultrasonography.

Appearance of the fetal posterior fossa at 11 + 3 to 13 + 6 gestational weeks on transabdominal ultrasound examination.

OBJECTIVES: To describe the sonographic appearance of the structures of the posterior cranial fossa in fetuses at 11 + 3 to 13 + 6 weeks of pregnancy and to determine whether abnormal findings of the brain and spine can be detected by sonography at this time. METHODS: This was a prospective study including 692 fetuses whose mothers attended Innsbruck Medical University Hospital for first-trimester sonography. In 3% (n = 21) of cases, measurement was prevented by fetal position. Of the remaining 671 cases, in 604 there was either a normal anomaly scan at 20 weeks or delivery of a healthy child and in these cases the transcerebellar diameter (TCD) and the anteroposterior diameter of the cisterna magna (CM), measured at 11 + 3 to 13 + 6 weeks, were analyzed. In 502 fetuses, the anteroposterior diameter of the fourth ventricle (4V) was also measured. In 25 fetuses, intra- and interobserver repeatability was calculated. RESULTS: We observed a linear correlation between crown-rump length (CRL) and CM (CM = 0.0536 × CRL - 1.4701; R2 = 0.688), TCD (TCD = 0.1482 × CRL - 1.2083; R2 = 0.701) and 4V (4V = 0.0181 × CRL + 0.9186; R2 = 0.118). In three patients with posterior fossa cysts, measurements significantly exceeded the reference values. One fetus with spina bifida had an obliterated CM and the posterior border of the 4V could not be visualized. CONCLUSIONS: Transabdominal sonographic assessment of the posterior fossa is feasible in the first trimester. Measurements of the 4V, the CM and the TCD performed at this time are reliable. The established reference values assist in detecting fetal anomalies. However, findings must be interpreted carefully, as some supposed malformations might be merely delayed development of brain structures.

Left ventricular function many years after recovery from pre-eclampsia.

OBJECTIVE: Epidemiological observations have shown that women with pre-eclampsia are at increased risk for subsequent development of cardiovascular disease. We evaluated maternal haemodynamics in asymptomatic women many years after pre-eclampsia and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome. DESIGN: Case-control study. SETTING: University-based department of obstetrics. POPULATION: Forty-eight women, 13-18 years after the affected pregnancy: 17 women with a history of HELLP syndrome, 14 women with a history of pre-eclampsia and 17 women following normal pregnancy (control group). METHODS: Echocardiographic examination was performed in all groups, recording the isovolumetric contraction time and isovolumetric relaxation time (ICT + IVRT), ejection time (ET), myocardial performance index (MPI), transmitral early to atrial filling velocity ratio (MV-E/MV-A), stroke volume (SV) and cardiac output (CO). MAIN OUTCOME MEASURES: Cardiac function. RESULTS: Women with previous HELLP syndrome showed a significantly increased MPI (0.34 versus 0.26; P = 0.008) and ICT + IVRT (442.16 versus 415.03; P = 0.01); MV-E/A, SV, ET and CO were not significantly different. Women with a history of pre-eclampsia showed a significantly increased MPI (0.36 versus 0.26; P = 0.006) and decreased ET (317.3 versus 328.93; P = 0.04); ICT + IVRT, MV-E/A, SV and CO were not significantly different. CONCLUSION: This study confirms epidemiological observations that women with pre-eclampsia are at increased risk for subsequent development of cardiovascular disease. Many years after HELLP syndrome or pre-eclampsia, asymptomatic women have an increased risk for impaired cardiac function as shown by an increased MPI.

Spontaneous isolated midtrimester fracture of tibia and fibula in a normal fetus with in utero healing and good long-term outcome.

We report a case of spontaneous intrauterine fracture of the right tibia and fibula in an otherwise healthy fetus at 20 weeks of gestation. The fracture healed in utero in an abnormal position. Postnatal development of the baby was normal with spontaneous correction of the angulation, and no underlying disease could be discovered. Spontaneous isolated fetal fractures are rare and need to be differentiated from fractures that occur due to trauma or underlying skeletal diseases.

Reference values for Doppler parameters of the fetal anterior cerebral artery throughout gestation.

AIM: To construct normal reference values for Doppler parameters in 2 anatomical segments of the fetal anterior cerebral artery (ACA) throughout pregnancy. METHODS: The ACA was evaluated in 373 normally growing fetuses from 20 to 40 weeks of gestation. The first segment of the ACA (ACA-S1) was recorded just after its origin from the internal carotid artery in the same plane as the middle cerebral artery (MCA). The second segment (ACA-S2) was recorded distal to the outlet of the anterior communicating artery. RESULTS: The ACA pulsatility index (PI) behaved similarly in both segments, with a constant increase until 28 weeks followed by a decrease until the end of pregnancy [ACA-S1 PI = 3.49 - 0.37 x gestational age (GA) - (0.0063 x GA(2)), SD = 0.6 - 0.061 x GA - (0.001 x GA(2)); ACA-S2 PI = 1.54 - 0.22 x GA - (0.0037 x GA(2)), SD = 0.206 + (0.0037 x GA)]. Peak systolic velocities in both segments showed a constant increase from 20 to 40 weeks of gestation. No significant differences were found between the 2 segments with regard to any Doppler parameter. However, the angle of insonation and the time spent on examination were significantly lower and reproducibility was better for ACA-S1. CONCLUSION: Despite showing similar Doppler values, ACA-S1 has a higher reliability than ACA-S2 and can be recorded in the same anatomical projection as the MCA.

Three-dimensional sonographic calculation of the volume of intracranial structures in growth-restricted and appropriate-for-gestational age fetuses.

OBJECTIVES: To evaluate the feasibility and reproducibility of volume segmentation of fetal intracranial structures using three-dimensional (3D) ultrasound imaging, and to estimate differences in the volume of intracranial structures between intrauterine growth-restricted (IUGR) and appropriate-for-gestational age (AGA) fetuses. METHODS: Total intracranial, frontal, thalamic and cerebellar volumes were measured using 3D ultrasound imaging and Virtual Organ Computer-aided AnaLysis (VOCAL) in 39 IUGR and 39 AGA fetuses matched for gestational age, at 28-34 weeks of gestation. Volumes of, and ratios between, structures were estimated, and differences between IUGR and AGA fetuses were calculated. Volume measurements were performed by two observers, and interobserver and intraobserver intraclass correlation coefficients (ICCs) were calculated for each structure. RESULTS: Volumes were satisfactorily obtained in all fetuses. All net volumes except those for the thalamus (P = 0.23) were significantly smaller (P = 0.001) in IUGR fetuses. After adjusting volumes for biparietal diameter the frontal volume was significantly smaller (P = 0.02) and the thalamic volume significantly greater (P = 0.03) in IUGR fetuses than in AGA fetuses. Significant intergroup differences in the ratios between structures were found only in those involving the frontal region. Interobserver ICCs were as follows: total intracranial 0.97 (95% CI, 0.92-0.98), cerebellar 0.69 (95% CI, 0.44-0.75), frontal 0.66 (95% CI, 0.42-0.79) and thalamic 0.54 (95% CI, 0.37-0.72). CONCLUSIONS: IUGR fetuses show differences in the volume of intracranial structures compared with AGA fetuses, with the largest difference found in the frontal region. These differences might be explained by in-utero processes of neural reorganization induced by chronic hypoxia.

[Long term follow-up of children with increased nuchal translucency and normal karyotype on first trimester sonography]. / Langzeit-Follow-up von Kindern mit erhöhter Nackentransparenz und normalem Karyotyp in der Ersttrimestersonografie.

BACKGROUND: A prospective study to evaluate long-term pregnancy outcome and childhood development of chromosomally normal foetuses with increased nuchal translucency thickness (NT) at 10-14 weeks of gestation. METHODS: Between Jan 1, 1997 and Dec 31, 2001 78 foetuses with increased NT but normal karyo-type were identified from the database of the Department of Obstetrics and Gynaecology at Innsbruck Medical University. To evaluate long term cognitive abilities and social skills standardized questionnaires ("Elternfragebogen zur ergänzenden Entwicklungsbeurteilung bei den kinderärztlichen Vorsorgeuntersuchungen U6 bis U9"EEE U6-U9; "Kognitive Probleme bei Kindern und Jugendlichen--Vorstellung eines Fragebogens" KOPKIJ) were used. 41 children with increased nuchal translucency were compared with 41 control children matched for date of birth, gestational and maternal age. RESULTS: Follow-up data could be collected in 44 cases. 2 out of 78 foetuses died intrauterine, one infant died after birth. Two out of the 41 surviving infants showed genetic disorders. There was no significant difference in cognitive delay between children with increased NT and controls (9.8% vs. 2.4%, p=0.361). CONCLUSION: Our findings suggest that chromosomally normal foetuses with increased nuchal translucency in the first-trimester scan do not have an increased risk for a significant cognitive developmental delay in an observation period of up to six years.

Impact of nuchal cord on measurement of fetal nuchal translucency thickness.

OBJECTIVE: To define the impact of nuchal cord on the measurement of fetal nuchal translucency thickness (NT). METHODS: Between December 2004 and June 2006, we examined prospectively 53 fetuses that were observed on routine first-trimester ultrasound examination between 11 + 3 and 13 + 6 weeks of gestation to have nuchal cord causing an indentation in the skin in the nuchal region. The fetuses were re-examined after a median interval of 132 min, when the cord was no longer around the neck and indentation of the skin had resolved. Various NT measurements (highest, lowest, mean) with the cord located around the neck (nuchal cord) were compared with NT measurements in the absence of nuchal cord ('true' NT) in the same fetuses. Measurements were considered to be equal when they were within mean +/- 1.96 SD, defined by our own intraobserver repeatability according to the method of Bland and Altman. RESULTS: The mean of the largest and the smallest of six measurements in the presence of nuchal cord fell within the mean +/- 1.96 SD of our own intraobserver repeatability, i.e. gave a correct estimate of the true NT, in 80% of fetuses, while the NT was overestimated in 10% and underestimated in 10% of fetuses. The largest and the smallest of six measurements in the presence of nuchal cord gave an underestimate of the true NT in 2% of fetuses and an overestimate in 4% of fetuses, respectively. CONCLUSION: There is a wide scattering of measurements in fetuses with nuchal cord in comparison to the same fetuses in the absence of nuchal cord. This prevents accurate prediction of the true NT, although the largest and smallest of repeat measurements with nuchal cord can allow calculation of the highest and lowest possible risks, respectively. These facts must be taken into consideration in counseling patients.

Prediction of fetal anemia in rhesus disease by measurement of fetal middle cerebral artery peak systolic velocity.

OBJECTIVE: In red blood cell (RBC) isoimmunized pregnancies fetal anemia is associated with a hyperdynamic circulation. The aim of the present study was to examine further the possible value of fetal middle cerebral artery peak systolic velocity (MCA-PSV) in the management of affected pregnancies. METHODS: A reference range of fetal MCA-PSV with gestation was constructed from the study of 813 normal singleton pregnancies at 20-40 weeks' gestation. Fetal MCA-PSV was also measured in 58 fetuses from RBC isoimmunized pregnancies, with maternal hemolytic antibody concentration of >15 IU/mL at 19-38 weeks' gestation and within 10 days of measurement of fetal hemoglobin concentration in blood obtained either by cordocentesis (n = 43) or at delivery (n = 15). In the RBC isoimmunized pregnancies each of the measured MCA-PSV and hemoglobin concentrations was expressed as a delta value (difference in SDs from the normal mean for gestation). Regression analysis was used to determine the significance of the association between delta MCA-PSV and delta fetal hemoglobin concentration. RESULTS: In the normal pregnancies there was a significant increase in fetal MCA-PSV with gestation (mean MCA-PSV = 10(0.0223 x GA + 0.963)). In RBC isoimmunized pregnancies the fetal MCA-PSV was increased and there was a significant association between delta MCA-PSV and delta hemoglobin concentration (delta hemoglobin = (delta MCA-PSV + 0.093)/-0.356; R(2) = 0.638, P < 0.0001). An MCA-PSV of mean + 1.5 SDs detected 96% of severely anemic fetuses, with a hemoglobin deficit of at least 6 SDs, for a false-positive rate of 14%. CONCLUSION: Measurement of fetal MCA-PSV is a useful method of assessing fetal anemia. In the clinical management of isoimmunized pregnancies a cut-off in MCA-PSV of mean + 1.5 SDs can identify nearly all severely anemic fetuses with a low false-positive rate.

Fetal middle cerebral artery peak systolic velocity in the investigation of non-immune hydrops.

OBJECTIVE: In some cases of non-immune hydrops there is congenital or acquired fetal anemia. The aim of this study was to investigate the potential value of fetal middle cerebral artery peak systolic velocity (MCA-PSV) in the assessment and management of non-immune hydrops due to anemia. METHODS: Fetal MCA-PSV and fetal hemoglobin concentration, in blood obtained by cordocentesis, were measured in 16 singleton pregnancies referred to our unit for further investigations because of a diagnosis of non-immune hydrops fetalis. In all cases a detailed ultrasound examination demonstrated moderate or severe ascites, with or without skin edema, and pericardial or pleural effusions. Furthermore, there were no obvious malformations to account for the hydrops. In each fetus the measured MCA-PSV and hemoglobin concentration were expressed as delta values (the difference in SD from the normal mean for gestation). Regression analysis was used to determine the significance of the association between delta MCA-PSV and delta fetal hemoglobin concentration. In addition, we searched our database to identify the sonographic features and hemoglobin concentration of fetuses with congenital infection. RESULTS: In the 16 cases of non-immune hydrops there were seven with parvovirus B19 infection, one each of alpha-thalassemia and primary cardiomyopathy and seven with no obvious explanation for the hydrops. There was a significant association between delta MCA-PSV and delta hemoglobin concentration (delta hemoglobin = (delta MCA-PSV + 0.1437)/-0.4154; R(2) = 0.7202; P < 0.0001). In 10 of the cases the fetal hemoglobin concentration was more than 4 SD below the normal mean for gestation and in all these cases the MCA-PSV was more than 2 SD above the normal mean for gestation. Our computer search identified an additional nine fetuses with parvovirus B19 infection and in all cases the predominant sonographic finding was ascites and the hemoglobin concentration was more than 4 SD below the normal mean. In contrast, only 3/14 fetuses with cytomegalovirus, toxoplasmosis, coxsackie B or Treponema infection had ascites and only 2/14 had a hemoglobin deficit of 4-6 SD. CONCLUSION: In the management of non-immune hydrops, measurement of fetal MCA-PSV can help identify the subgroup with fetal anemia.

Learning curve for sonographic examination of the fetal nasal bone at 11-14 weeks.

OBJECTIVE: To determine the number of ultrasound examinations necessary for training sonographers to examine accurately the fetal nasal bone at 11-14 weeks' gestation. METHODS: Fifteen sonographers with experience in measuring nuchal translucency were asked to examine the nasal bone during the routine 11-14-week scan. The supervising doctor recorded if the sonographer succeeded in obtaining the correct image. Each sonographer performed a total of 140 examinations, and the data were analyzed in seven groups of 20 examinations. In a second study, two sonographers with extensive experience in examining the nasal bone examined independently 100 consecutive patients at a median fetal crown-rump length of 65 (45-84) mm and median gestational age of 12 (11-14) weeks and recorded whether the nasal bone was absent or present. RESULTS: In the first group of 20 examinations, there was failure to obtain the correct image of the fetal profile in 1-5 (median, 4) cases. In the subsequent three groups, there was failure to obtain the correct image in 0-3 (median, 1) cases. In the fifth and sixth groups failure occurred in 0-2 (median, 0) cases and in the seventh group all sonographers obtained successful images of the fetal profile in all cases. One sonographer obtained successful images of all cases after the first 40 scans, four after the first 60 scans, six after the first 80 and two each after the first 100 and 120 scans. In the second study, there was agreement between the two sonographers that the nasal bone was absent in two and present in 98 of the 100 consecutive patients examined. CONCLUSION: The minimum number of scans required for an experienced sonographer to become competent in examining the fetal nasal bone is on average 80, with a range of 40-120.

Illness representations according to age and effects on health behaviors following coronary artery bypass graft surgery.

OBJECTIVES: To determine if illness representations differ as a function of age and how these representations, in conjunction with age, predict postoperative health behaviors. DESIGN: Prospective study of patients undergoing coronary artery bypass graft (CABG) surgery. SETTING: A large metropolitan hospital providing regional cardiac care for patients in a tri-state area, located in Pittsburgh, Pennsylvania. PARTICIPANTS: All consenting patients (N = 309) from a consecutive series of patients scheduled for CABG surgery between January 1992 and January 1994. To be eligible for participation, patients could not be scheduled for any other coincidental surgery (e.g., valve replacement), and could not be in cardiac intensive care or experiencing angina at the time of the referral. Participants were predominantly male (70%) and married (80%), and averaged 62.8 years of age. MEASUREMENTS: Postoperative self-reported health behaviors. RESULTS: Older participants awaiting CABG surgery were significantly more likely to believe old age to be the cause of their coronary heart disease (CHD) and significantly less likely to believe genetics, health-damaging behaviors, health-protective behaviors, and emotions to be the cause of their CHD than were younger participants awaiting surgery. Furthermore, the older participants were significantly more likely to believe they had no control over the disease and that the disease would be gone after surgery, and reported fewer postoperative health behavior changes than did younger participants. CONCLUSION: These findings demonstrate significant differences in illness representations as a function of age. Furthermore, differences in postoperative health behaviors were consistent with differing illness representations.

The Raynaud's Treatment Study: biofeedback protocols and acquisition of temperature biofeedback skills.

The Raynaud's Treatment Study (RTS) compared temperature biofeedback training and a behavioral control procedure (frontalis EMG biofeedback) with nifedipine-XL and a medication placebo for treatment of primary Raynaud's phenomenon (RP) in a large (N = 313) multicenter trial. The present study describes the RTS biofeedback protocols and presents data on the acquisition of digital skin temperature and frontalis EMG responses in the RTS. The findings point to substantial problems with acquisition of physiological self-regulation skills in the RTS. Only 34.6% of the Temperature Biofeedback group (N = 81) and 55.4% of the EMG Biofeedback group (N = 74) successfully learned the desired physiological response. In contrast, 67.4% of a Normal Temperature Biofeedback group (N = 46) learned hand warming. Multivariate analysis found that coping strategies, anxiety, gender, and clinic site predicted acquisition of hand-warming skills whereas variables related to RP disease severity did not. Physiological data showed vasoconstriction in response to the onset of biofeedback and also found that performance in the initial sessions was critical for successful acquisition. These findings indicate that attention to the emotional and cognitive aspects of biofeedback training, and a degree of success in the initial biofeedback sessions, are important for acquisition.

Scaling back goals and recalibration of the affect system are processes in normal adaptive self-regulation: understanding 'response shift' phenomena.

This comment addresses a set of phenomena that have been labeled 'response shift'. We argue that many of these phenomena reflect recalibration of a goal-seeking system and an affect-management system, both of which are involved in normal adaptive self-regulation. In brief, we hold that these systems act as feedback control mechanisms. The reference values for both systems continuously undergo gradual recalibration. Because in most circumstances the adjustments tend to occur with equivalent frequency in both directions, their cumulative effect is minimal. In situations of either unusually prolonged goal attainment (and overattainment) or unusually prolonged adversity (as occurs, e.g., with deteriorating health), the cumulative effect can be substantial. We believe that these latter recalibrations of reference value account for many response shift phenomena. Other such phenomena are accounted for by the principle of hierarchical organization among the self-regulatory goals that comprise the self.

Chest ultrasound in diagnosis of pulmonary embolism in comparison to helical CT.

UNLABELLED: To many people die because of undiagnosed pulmonary embolism. Common pulmonary embolism is the most unexpected mortal event in necropsy, antemortem correctly diagnosed in 18-39%. The diagnostic value of chest ultrasound (CUS) has been investigated. METHODS: 117 (68 women, 49 men) patients with clinical suspicion of pulmonary embolism underwent chest sonography and spiral computed tomography (CT). Final diagnosis has been made by CT respective with echo-cardiography, venous duplex sonography and fibrin dimer tests. RESULTS: Finally, 70 patients suffered from pulmonary embolism. The chest sonograms showed averaged 1.5 x 2.8 cm (0.5-8.5) large triangular or rounded hypoechoic lesions, mean 2.6 pro patient, similar in form and size as in CT. Fresh reperfusionable infarcts were homogenous and hypoechoic. Older infarcts were well demarcated, mainly wedge shaped. A hyperechoic reflex in the center corresponds to the bronchiole: a sign of segmental involvement. The sensitivity of chest ultrasound was 94%, the specificity 87%, positive predictive value 92%, negative predictive value 91%, accuracy 91%. Overall 61 patients had PE in CT, in 47 (67%) cases a direct emboli detection was possible. 14 patients had peripheral lung consolidations without detectable emboli, but fibrin-dimer tests were positive in all cases, there was deep vein thrombosis diagnosed and they showed signs of PE in echocardiography. Spiral CT showed a sensitivity of 85%, a specificity and a positive predictive value of 100%, a negative predictive value of 83% and an accuracy of 92%. CONCLUSION: CUS can improve diagnosis of pulmonary embolism. Sonography also reveals small infarcts which remain undetected with other imaging procedure such as helical CT.

Optimism and rehospitalization after coronary artery bypass graft surgery.

OBJECTIVE: To determine whether optimism predicts lower rates of rehospitalization after coronary artery bypass graft surgery for the 6 months after surgery. METHODS: A prospective, inception cohort design was used. The sample consisted of all consenting patients (N=309) from a consecutive series of patients scheduled for elective coronary artery bypass graft surgery at a large, metropolitan hospital in Pittsburgh, Pa. To be eligible, patients could not be scheduled for any other coincidental surgery (eg, valve replacement) and could not be in the cardiac intensive care unit or experiencing angina at the time of the referral. Participants were predominantly men (69.9%) and married (80.3%), and averaged 62.8 years of age. Recruitment occurred between January 1992 and January 1994. RESULTS: Compared with pessimistic persons, optimistic persons were significantly less likely to be rehospitalized for a broad range of aggregated problems (including postsurgical sternal wound infection, angina, myocardial infarction, and the need for another bypass surgery or percutaneous transluminal coronary angioplasty) generally indicative of a poor response to the initial surgery (odds ratio=0.50, 95% confidence interval=0.33- 0.76; P=.001). The effect of optimism was independent of traditional sociodemographic and medical control variables, as well as independent of the effects of self-esteem, depression, and neuroticism. All-cause rehospitalization also tended to be less frequent for optimistic than for pessimistic persons (odds ratio=0.77, 95% confidence interval=0.57-1.05; P=.07). CONCLUSIONS: Optimism predicts a lower rate of rehospitalization after coronary artery bypass graft surgery. Fostering positive expectations may promote better recovery.

Spousal caregivers' activity restriction and depression: a model for changes over time.

In this paper we examine the effects of increasing as well as decreasing caregiving demands on depressive symptomatology. In addition, we focus on spousal caregivers' activity restriction as an explanatory mechanism for changes in depressive symptomatology in the caregiving context. Two databases are used to answer our research questions. An increase of caregiving demands is assessed in study 1, which includes prospective data on 127 spousal caregivers of stroke, hip fracture, congestive heart failure and myocardial infarction patients. A decrease of caregiving demands is examined in study 2, which includes prospective data on 110 spousal caregivers of bypass operation patients. The results generally support the hypothesis that an increase in caregiving demands results in increased depressive symptomatology, while a decrease in caregiving demands reduces depressive symptomatology. The results also support the notion of activity restriction as a critical mediator of changes in depressive symptoms. Cross-sectionally it mediates the association between caregiving and depressive symptomatology, and longitudinally it contributes to changes in depressive symptomatology in both samples.

[Ultrasound diagnosis of rib and sternum fractures]. / Ultraschalldiagnostik von Rippen- und Sternumfrakturen.

PURPOSE: Lesions of the thoracic skeleton can sometimes be a problem in radiological diagnosis. Aim of the study was to investigate the value of ultrasound in the diagnosis of thoracic trauma in clinical practice. METHOD: Patients with thoracic trauma and suspected rib or sternal fracture were entered in the study. The results of the thoracic x-ray including a special target film and thoracic sonography were compared. RESULTS: 103 patients took part in the study (32 women, 71 men, average age 54.3 years). In x-ray the diagnosis of rib fracture was certain in 27 patients (30%). In US 56 patients (58%) had definitive signs of rib fracture. Because of multiple fractures in the same patients the total number of radiologically found rib fractures was 49, whereas 101 fractures could be detected by sonography. Also minimal pleural effusions could be found in 31 patients (32%) sonographically, only 18 of them were seen in x-ray. Larger effusions in six patients (6%) with serial rib fractures and haematothorax could all be diagnosed in x-ray and also US. The seven patients with suspected sternum fracture showed clear fracture signs in x-ray as well as US. CONCLUSIONS: Rib fractures could be found about twice as often US than x-ray. There was no difference in the diagnosis of sternal fracture. Detection of fluids (local haematoma and pleural effusion) is better via US than by x-ray. Therapeutical consequences may follow a quick bed-side diagnosis by US in a patient who needs intensive care. Other aspects after detection of a rib fracture US apart from thoracic contusion are psychological effects for the patients (usually they can cope better with their pain), the importance in the interpretation of the duration of incapacity to work and the additional information provided by expert opinions.

[Can pleurisy be detected with ultrasound?]. / Ist eine Pleuritis sonographisch darstellbar?

PURPOSE: It was the aim of this study to examine whether chest sonography is a useful method for diagnosing infective pleuritis. We assessed the pleural surface, the presence of subpleural consolidations and of pleural effusions. METHOD: 47 consecutive patients with the clinical diagnosis of pleuritis were examined by means of a 7 MHz linear transducer. We studied the pleural surface, the presence of subpleural consolidations and of pleural effusions. RESULTS: Pathologic findings could be seen in 43 patients (91%). The smooth echogenic pleural line was interrupted and was rough in appearance in 42 patients (89%). Subpleural consolidations from 0.2 to 2 cm in size were observed in 30 cases (63.8%). In 11 (23.4%) of these lesions, colour Doppler signals could be demonstrated. Pleural effusions were visible either as localised pleural effusions (24 patients, 51%) or as basal effusions (11 cases, 23.4%). Aspiration of pleural fluid was performed twice. In one case the diagnosis of tuberculosis could be proven by fast acid stain, in another patient a pleural empyema was drained successfully under ultrasound guidance. In 5 patients therapeutic consequences resulted from sonographic findings. CONCLUSION: We conclude that chest sonography is a sensitive and cost effective imaging method for the diagnosis of pleuritis. Aspiration of pleural fluid for further diagnostic or therapeutic procedures can be safely performed.

Pessimism, age, and cancer mortality.

Cancer patients (N = 238) receiving palliative radiation treatment were followed for 8 months; 70 patients had died by the 8-month follow-up. Controlling for site of cancer and level of symptomatology at baseline, the authors studied the independent effects on mortality of pessimism, optimism, and depression. The findings show that the endorsement of a pessimistic life orientation is an important risk factor for mortality, but only among younger patients (ages 30-59). Attempts to replicate this finding with conceptually related constructs such as depression or optimism did not yield significant associations for either younger or older patients, suggesting that negative expectations about the future may contribute to mortality in unique ways. The authors conclude that attempts to link psychosocial factors to mortality should focus on specific psychological constructs instead of diffuse, global measures that cover many psychological phenomena and that the role of psychological processes in mortality may vary dramatically depending on age.