Counseling lesbian patients about getting pregnant.

OBJECTIVE: To describe an approach to counseling lesbian patients about getting pregnant. SOURCES OF INFORMATION: Information in this paper is based on evidence from randomized controlled trials (level I evidence), non-randomized trials (level II evidence), expert opinion (level III evidence), and government regulations. MAIN MESSAGE: We review 5 steps that comprise an approach to counseling lesbian patients about getting pregnant safely and efficiently. These steps are preconception care (including counseling, testing, and immunization); donor choice (including explaining the risks and benefits of choosing between a known or anonymous donor and the difference between fresh and frozen semen); donor testing (including Health Canada's requirements for semen processing and recommendations for testing before home insemination); ordering the semen (including information about sperm banks and the need for "Canadian compliant" semen); and the insemination process (including techniques for monitoring ovulation and various methods of insemination). CONCLUSION: Primary care physicians can help lesbians achieve pregnancy by providing education, testing, referrals, and insemination services.

Mycetoma due to Pseudallescheria boydii and co-isolation of Nocardia abscessus in a patient injured in road accident.

We report the case of a patient who developed a mycetoma after experiencing a road accident. From surgical biopsies Pseudallescheria boydii was isolated. Subsequently, after the infection had been treated with itraconazole, a Gram-positive bacterium, identified as the newly described species Nocardia abscessus, was cultured from wound fluids.

[Plastic surgery of the anorectal area. Indications, technique and outcome]. / Plastische Chirurgie im Anorektalbereich. Indikation, Technik und Ergebnisse.

Anal canal stenosis with alteration of the sensoric continence or mucosal ectropion may occur after anorectal operations. Island flaps with perianal skin or the VY-anoplasty are simple plastic methods to reconstruct the anorectal region and cure patients--who often have suffered for a long time--from anal strictures or mucosal ectropion. In the period from 1994-1998 we reconstructed the anodermal region of seven patients using one of the above mentioned anorectal plastic procedures. Three patients complained of an anal stenosis and one patient suffered from an ectropion of the rectal mucosa after an improperly performed Whitehead hemorrhoidectomy. Three patients had a sensomotoric incontinence twice due to a congenital anal atresia and in one case caused by an accident. All patients were highly pleased after the operation--no complication occurred.

[The parathyrotoxic crisis - a surgical emergency]. / Die parathyreotoxische Krise - ein chirurgischer Notfall.

INTRODUCTION: The extremely rare but life-threatening hypercalcemic crisis is caused by an exacerbation of a chronic hyperparathyroidism. The etiologic reasons for this exacerbation are conditions which increase the serum calcium level in addition to the hyperparathyroidism with a complete breakdown of the calcium homeostasis, e. g. malignant tumors, primary and tertiary hyperparathyroidism, vitamin D poisoning or overdoses of calcium, vitamin D and calcium-containing ionizer in patients with renal insufficiency. METHODS: We present the clinical course of five patients with an acute hypercalcemic crisis and discuss the diagnostic procedure and the principles of surgical treatment with regard to the current literature. RESULTS: A hypercalcemic crisis develops if the total serum calcium concentration is over 4 mmol/l and parathormone over 90 pmol/l. The resulting syndrome is manifested by nausea and vomiting, polyuria and consecutive dehydration and hypotonia culminating in lethargy, hallucinations and coma. Hypercalcemia is the single most important diagnostic finding. CONCLUSION: The emergency therapy predominantly consists on the one hand in rehydration and parallel stimulation of diuresis. Urgent surgery is required if conservative therapy is not successful.

[Littré's hernia--clinical aspects and review of the history]. / Geschichte und Klinik der Littré-Hernie.

In 1700, the French surgeon Alexandre de Littré described for the first time a new form of inguinal hernia. This hernia varied from the known forms of hernias in its clinical course and in the postmortem examination results performed by Littrè himself. The characteristic feature of this hernia was the fact that the entire circumference of the bowel wall was not part of the hernial sac, but only the antimesenteric part of the intestinal wall. The underlying pathomechanism was explained 100 years later by Meckel. In a scientific paper about hernias some years earlier, Richter described the intestinal wall hernia, and this initiated the confusing use of the clinical entity known as the Richter-Littré hernia in Germany. In this case report we describe the historic development of this entity.

Comparison based on age of baseline electrocardiographic abnormalities in non-Q-wave myocardial infarction. VANQWISH Trial Research Investigators. Veterans Affairs Non-Q-Wave Infarction Strategies In-Hospital.

OBJECTIVE: To compare the incidence of electrocardiographic abnormalities between older (age > or = 70 years) and younger patients presenting with acute non-Q-wave myocardial infarction. DESIGN: Retrospective review of qualifying electrocardiograms in 918 patients enrolled in the multicenter Veterans Affairs Non-Q-Wave Infarction Strategies In-Hospital (VANQWISH) study. SETTING: Seventeen Department of Veterans Affairs medical centers. PARTICIPANTS: A total of 918 patients (224 > or = 70 years old) with acute non-Q-wave myocardial infarction. MEASUREMENTS: Comparison of electrocardiograms in patients aged > or = 70 years and younger patients for presence of left ventriculary hypertrophy, widened QRS complex, ST and T wave abnormalities, rhythm other than sinus, heart rate > or = 80 beats/minute, and location of acute non-Q-wave myocardial infarction. RESULTS: Left ventricular hypertrophy and ST depression > or = 1 mm were significantly more frequent in older than in younger patients. CONCLUSIONS: Older patients presenting with non-Q-wave myocardial infarction have a greater incidence of left ventricular hypertrophy and ST depression on their electrocardiograms than younger patients. Both of these electrocardiographic findings have previously been associated with increased risk of death and recurrent myocardial infarction and may help account for the worse prognosis of non-Q-wave myocardial infarction in older patients.

Technetium Tc 99m sestamibi myocardial perfusion imaging: current role for evaluation of prognosis.

Like 201Tl imaging, technetium Tc 99m sestamibi (MIBI) myocardial imaging can be used with exercise and pharmacologic testing to assess the presence of coronary artery disease. An increasing body of literature indicates that MIBI can also be used to assess risk of future cardiac events such as myocardial infarction or death. This article summarizes the current status of MIBI imaging for evaluating prognosis in patients with known or suspected coronary artery disease.

[Experiences in surgery of proctologic diseases in patients with HIV infection]. / Erfahrungen in der Chirurgie proktologischer Erkrankungen HIV-Infizierter.

Individuals who are seropositive for the human immunodeficiency virus (HIV) often suffer from disorders affecting the anorectum, but unfortunately the best kind of treatment frequently seems questionable. In a retrospective investigation we reviewed 29 HIV-positive patients with anorectal lesions who had experienced a proctologic operation. Our impression correlates with other findings according to which HIV-positive patients in advanced stages have a poorer post-operative outcome in terms of morbidity and survival than patients in an early CDC disease stage. This implies that the indication for a proctologic operation in an immunocompromised state has to be considered carefully.

Benign and malignant cells in effusions: diagnostic value of image DNA cytometry in comparison to cytological analysis.

Identifying tumor cells in body cavity fluids reliably is a well-known diagnostic problem. Since cytometric quantitation of nuclear DNA content appears to be a promising new tool in the diagnosis and prognostic evaluation of many solid human tumors, we examined its validity in detecting malignant cells in cytologically positive effusions. For this purpose, image DNA cytometric measurements, including the evaluation of DNA-ploidy and the calculation of the DNA index (DI), were performed in 80 body cavity fluids. The results were correlated with cytology, clinical course and final histological diagnoses. We used aneuploidy, as shown by interactive image DNA cytometry, as a marker for the malignancy of cells that occur in body cavity fluids with a 100% specificity and 94.8% sensitivity. Cytological investigation showed a 92.3% specificity and 95.4% sensitivity. Combining both methods raised the specificity to 100% and the sensitivity to 98.5% and had a positive predictive value of 100% and a negative predictive value of 93.8%. The DNA-index (DI) was significantly higher in malignant effusions than in benign effusions: 1.5 +/- 0.74 (mean +/- SD) versus 1.11 +/- 0.26 (p < 0.05). Along with the difficult cytological evaluation of malignant cells in body cavity fluids, image DNA cytometry can be a helpful additional method for evaluating these cells. Combining the two techniques results in a highly specific and sensitive prediction of malignant cells. We, therefore, suggest using these methods for the reliable identification of tumor cells in effusions.

[Increased CA-19-9 caused by a splenic cyst: a rare differential diagnosis]. / CA19-9-Erhöhung durch eine Milzzyste: Eine seltene Differentialdiagnose.

Adenocarcinoma of the gastrointestinal tract, particularly primary adenocarcinoma of the pancreas lead to elevation of serum carbohydrate 19-9 (CA19-9) levels. Some benign disorders, like inflammatory diseases also cause CA19-9 tumor marker elevation. An extremely rare entity are benign splenic cysts which express this tumormarker as reported here.

Risk stratification with pre-hospital discharge exercise technetium-99m sestamibi myocardial tomography in men after acute myocardial infarction.

BACKGROUND: Exercise thallium-201 imaging early after acute myocardial infarction (MI) may provide information concerning risk of future cardiac events. The prognostic value of exercise technetium-99m sestamibi (MIBI) single-photon emission computed tomography in such patients has not been established. METHODS AND RESULTS: Submaximal exercise stress testing with MIBI tomography was done before hospital discharge in 134 consecutive men after acute MI. Patients were monitored for occurrence of late cardiac events (nonfatal MI or cardiac death). Coronary revascularization was done in 31 patients (23%) < or = 3 months after testing. Nonfatal MI or cardiac death occurred in 30 (23%) of the overall group of 133 patients monitored (mean 35+/-19 months) and in 25 (25%) of the 102 patients treated medically. A history of congestive heart failure, failure to reach 85% of age-predicted maximal heart rate, and an isolated fixed MIBI defect were associated with significantly increased risk (p < 0.05) of a late cardiac event in both groups of patients. A reversible MIBI defect was not associated with increased risk. In a multivariable Cox proportional hazards model, only a history of congestive heart failure (relative risk 4.2, 95% confidence interval [CI] 1.7 to 10.4, p < 0.002) and an isolated fixed MIBI defect (relative risk 2.1, 95% CI 1.1 to 4.3, p < 0.05) were independent predictors of increased risk in the total group of 133 patients. In the 102 patients treated medically, only a history of congestive heart failure (relative risk 4.9, 95% CI 1.9 to 13.1) and achievement of 85% of age-predicted maximal heart rate (relative risk 0.13, 95% CI 0.02 to 0.9) were independent predictors of risk. CONCLUSIONS: Early post-MI submaximal exercise testing with MIBI tomography provides limited prognostic information for late cardiac events. An isolated fixed MIBI defect is associated with increased risk but not as strongly as other variables, particularly a history of congestive heart failure.

Influence of race on the prediction of cardiac events with stress technetium-99m sestamibi tomographic imaging in patients with stable angina pectoris.

The prognostic value of myocardial perfusion imaging in African-Americans is unknown. This study compared the prediction of cardiac events of stress technetium-99m (Tc-99m) sestamibi single-photon emission computed tomography (SPECT) imaging in symptomatic Caucasian and African-American patients. Prospectively collected stress Tc-99m sestamibi tomographic imaging data from 4 medical centers, with follow-up information in 1,086 Caucasian and African-American patients, were analyzed in a core statistical laboratory. Primary events of cardiac death and nonfatal myocardial infarction and secondary events of all-cause mortality were analyzed using Kaplan-Meier survival analysis and Cox proportional-hazards multivariable model. Normal images in both African-Americans and Caucasians were associated with a low-annual cardiac event rate, whereas abnormal images were significantly associated with a higher cardiac event rate. The highest predictor of cardiac events was multivessel abnormality in both races. Use of this technique could identify patients at high risk and potentially reduce the high-cardiac event rate in African-Americans by utilizing appropriate therapies.

Diagnostic accuracy of dipyridamole technetium 99m-labeled sestamibi myocardial tomography for detection of coronary artery disease.

BACKGROUND: The diagnostic accuracy of exercise 99mTc-labeled sestamibi and intravenous dipyridamole 201Tl-labeled myocardial tomography is established. The accuracy of dipyridamole stress 99mTc-labeled sestamibi myocardial tomography for the detection of coronary artery disease has not been reported. METHODS AND RESULTS: Our purpose was to determine the diagnostic accuracy of same-day, rest-dipyridamole stress 99mTc-labeled sestamibi myocardial single-photon emission computed tomography (SPECT) compared with coronary angiography. Two hundred forty-four patients who were unable to exercise adequately underwent both dipyridamole 99mTc-labeled sestamibi SPECT and coronary angiography within 6 months. Dipyridamole was administered intravenously in a standard dose of 0.56 mg/kg for 4 minutes. Cardiac and noncardiac side effects were recorded. The presence of coronary stenoses of 50% or greater diameter reduction in each of the major coronary arteries was compared with imaging data in corresponding myocardial perfusion beds. The patient population was predominately (98.8%) male with a mean age of 63 +/- 9 years (range 33 to 83 years). The majority of patients had stable angina (88%). Eighty-four patients (35%) gave a prior history of myocardial infarction; 44 patients (18%) had a history of congestire heart failure. The principal limitation to exercise stress was peripheral vascular disease in 62 patients (26%). No serious side effects occurred during dipyridamole stress; 14% of patients had chest pain and 8% of patients had 1 mm or greater ST segment depression. Of the 204 patients with documented coronary stenoses, 43 (21%) had single-vessel disease and 161 (79%) had multivessel disease. The sensitivity was 93% (40/43 in patients with single-vessel disease) and 91% (146/161 in patients with multivessel disease). Overall sensitivity was 91%. The specificity was 28% (11/40) in this population with a high prestest probability of coronary artery disease and posttest referral for cardiac catheterization. CONCLUSION: 99mTc-labeled sestamibi myocardial tomography in conjunction with intravenous dipyridamole stress is a safe and sensitive method for the detection of coronary artery disease. The diagnostic accuracy of dipyridamole stress 99mTc-labeled sestamibi SPECT for the detection of coronary artery disease is similar to that reported for exercise stress 99mTc-labeled sestamibi tomography, making this a suitable alternative for the evaluation of patients who are unable to exercise adequately.

[Women in surgery--equal surgeons]. / Frauen in der Chirurgie--Ebenbürtige Chirurgen?

In the specialty "surgery" women are underrepresented, especially in leading positions. The reason for that is not less motivation, less ability or less capacity of women, but the working conditions. For women in surgery working conditions are so unfavourable that only few women make their career in surgery.

Clinical importance and prognostic value of the image-DNA-cytometry for patients with gastric cancer.

Image-DNA-cytometric analysis was performed retrospectively on air-dried touch preparations from gastric carcinoma from 122 patients who underwent surgery from 1989-1994. The results of DNA cytometry were compared with conventional histologic staging and grading. Aneuploidy could be verified in 81 cases (66.3%), and a significant correlation was demonstrated between aneuploidy and a high incidence of lymph node metastases, whereas no correlation with tumor type and histologic grade was detected. Thus DNA ploidy may by useful in predicting prognosis in gastric cancer.

Effect of the stress level achieved during symptom-limited exercise technetium-99m sestamibi myocardial tomography on the detection of coronary artery disease.

BACKGROUND: The stress level achieved during exercise thallium 201 myocardial imaging may influence its sensitivity for detecting coronary artery disease (CAD). The effect of exercise adequacy on the accuracy of technetium-99m sestamibi (MIBI) imaging has not been studied. HYPOTHESIS: The study was undertaken to assess the effect of exercise level achieved on sensitivity for detecting CAD. METHODS: A consecutive series of 250 patients (mean age 60 +/- 10 years) with CAD by angiography underwent symptom-limited exercise MIBI single-photon emission computed tomography. Single-vessel CAD was found in 66 patients, double-vessel CAD in 84, triple-vessel CAD in 80, and left main disease in 20. RESULTS: No significant differences were found in sensitivities of an abnormal MIBI scan or a reversible defect among 102 patients reaching 85% of age-predicted heart rate and 148 who did not (82 vs. 89% and 66 vs. 70%, respectively, p = NS). Patients (n = 128) able to exercise < or = 6 min had a higher incidence of abnormal scans and reversible defects than 122 patients with a greater exercise duration (91 vs. 82% and 75 vs. 61%, respectively, both p < 0.05). Sensitivity of an abnormal MIBI scan for multivessel disease was greater than for single-vessel disease in patients who achieved > or = 85% of age-predicted heart rate (91 vs. 59%, p < 0.01) and in those who exercised > 6 min (89 vs. 66%, p < 0.01). No significant differences in the sensitivities of an abnormal MIBI study for multivessel versus single-vessel CAD were seen in patients achieving lower peak levels of exercise. Sensitivity of ischemic ST depression was lower than that of MIBI tomography at all levels of exercise. CONCLUSIONS: The sensitivity of exercise MIBI tomography for angiographic CAD is relatively independent of the peak heart rate achieved. Exercise duration of > 6 min is associated with a significantly higher MIBI abnormality rate than a duration of > 6 min, possibly reflecting the effect of myocardial ischemic burden on exercise ventricular function. Regardless of level of stress or its duration, exercise MIBI tomography improves the sensitivity for CAD detection compared with stress-induced ischemic ST depression.

Dipyridamole technetium 99m sestamibi myocardial tomography for preoperative cardiac risk stratification before major or minor nonvascular surgery.

The value of dipyridamole technetium 99m sestamibi (MIBI) tomography for preoperative cardiac risk stratification was assessed in 285 consecutive patients being considered for nonvascular surgery. A "major" (n = 140) or "minor" (n = 89) nonvascular procedure was later done in 229 of these patients < or = 4 months after dipyridamole testing. Perioperative cardiac events (unstable angina, acute ischemic pulmonary edema, nonfatal myocardial infarction, or cardiac death) occurred in 11 (8%) patients undergoing major nonvascular surgery and 1 (1%) undergoing a minor procedure. The only clinical or scintigraphic variables associated with significantly increased perioperative cardiac risk in patients having major surgery were Goldman class > or = II, an abnormal MIBI scan, and a fixed perfusion defect. In these patients, cardiac events occurred in 1% of those who had a normal MIBI study, 14% of those with an abnormal scan (p < 0.01), 12% with a reversible MIBI defect (p = 0.29), and 17% with a fixed MIBI defect (p < 0.01). In the 60 patients whose Goldman class was > or = II, only an abnormal MIBI study and a fixed perfusion defect were associated with incremental risk of a perioperative cardiac event. The incidence of perioperative cardiac events in these patients was 4% with a normal MIBI scan, 27% with an abnormal study (p < 0.05), 24% with a reversible MIBI defect (p = 0.45), and 37% with a fixed defect (p < 0.01). Event rates were low in patients having minor nonvascular surgery; none of the 25 with a normal MIBI study and only 1 of the 64 with an abnormal scan had a perioperative cardiac event (p = not significant (NS). We conclude that dipyridamole MIBI tomography can provide important prognostic information in patients having major nonvascular surgery. A normal MIBI study indicates a low risk of perioperative cardiac events, whereas an abnormal study in patients with Goldman class > or = II undergoing major surgery is associated with significantly increased risk. The prognostic value of MIBI tomography in patients at low clinical risk undergoing minor surgery is limited.

Dipyridamole technetium-99m sestamibi myocardial tomography in patients evaluated for elective vascular surgery: prognostic value for perioperative and late cardiac events.

Dipyridamole thallium-201 myocardial imaging can provide information regarding risk of perioperative cardiac events in patients being considered for vascular surgery. The value for this purpose of myocardial imaging with technetium-99m sestamibi (MIBI), a radiotracer with biokinetic and imaging properties different from thallium-201, has not been established. To this end the prognostic value of dipyridamole MIBI tomography for perioperative and late cardiac events was evaluated in 229 consecutive patients being considered for elective vascular surgery. Vascular surgery was done < or = 3 months after testing in 197 of these patients. Perioperative cardiac events (cardiac death, nonfatal myocardial infarction, unstable angina, or ischemic pulmonary edema) occurred in 9 (5%) patients. The rate of such events was 3% in patients with normal MIBI results, 5% in those with abnormal results, and 6% in patients with a reversible MIBI defect (both p = NS). When patients with abnormal MIBI results who had preoperative cardiac interventions (coronary revascularization or an increase in antiischemic medical therapy) were compared with with those who did not, no significant differences in the occurrence of perioperative cardiac events were found between these two groups either. A group of 172 medically treated patients who survived vascular surgery and did not have a nonfatal perioperative cardiac event was then monitored (mean 21 +/- 14 months) for the occurrence of a serious late cardiac event (nonfatal myocardial infarction or cardiac death). Event-free survival (Mantel-Cox) was significantly less in patients with abnormal studies compared with those with normal scan results. Late cardiac events occurred in 26 (15%) patients, with those having an abnormal MIBI result showing a significantly greater event rate than those with normal results (26% vs 4%, p < 0.0001). The rate of late cardiac events was 33% in patients with a reversible MIBI defect (p < 0.001) and 23% in those with a fixed defect (p < 0.03). Independent Cox multivariable predictors of increased risk of late cardiac events were a history of diabetes mellitus (relative risk [RR] 2.2, 95% confidence interval [CI] 1.0 to 4.9), an abnormal MIBI study (RR 3.7, 95% CI 1.2 to 11.4), and a reversible MIBI defect (RR 2.7, 95% CI 1.2 to 6.1). We conclude that, although its ability to assess increased perioperative cardiac risk remains uncertain, dipyridamole MIBI tomography does provide important prognostic information regarding the risk of serious cardiac events in patients having vascular surgery. The presence of an abnormal MIBI result, specifically one demonstrating a reversible perfusion defect, is associated with significantly increased risk.

Prognostic value of predischarge dipyridamole technetium 99m sestamibi myocardial tomography in medically treated patients with unstable angina.

Recently developed unstable angina clinical practice guidelines have recommended risk stratification with dipyridamole thallium-201 myocardial imaging in patients at "intermediate" pretest clinical risk who cannot exercise maximally. The prognostic value of predischarge dipyridamole technetium 99m sestamibi (MIBI) tomography has not been assessed in this clinical setting. To this end, 128 medically treated patients with unstable angina at intermediate pretest clinical risk underwent follow-up for 16 +/- 11 (mean +/- SD) months after predischarge intravenous dipyridamole MIBI tomography. An abnormal MIBI scan result was present in 99 patients (77%), of whom 47 had one or more reversible and 76 had one or more fixed perfusion defects. Cardiac events occurred in 68 (53%) patients after dipyridamole testing: recurrent unstable angina (n = 36), nonfatal acute myocardial infarction (n = 6), or death (n = 26). A cardiac event occurred in 10% of patients with normal MIBI tomography results compared with 69% of those with abnormal results (p < 0.01). Event rates associated with specific perfusion defects were similar (reversible = 68%; fixed = 71%) and were greater than rates in patients without defects (both p < 0.05). Clinical variables associated with increased risk of cardiac events by univariate analysis included a history of congestive heart failure, prior myocardial infarction, and diabetes mellitus (all p < 0.05). Independent multivariable predictors (Cox proportional hazards model) of any cardiac event were an abnormal result of MIBI scan (relative risk [RR] = 4.3, 95% confidence interval [CI] 1.5 to 12.0) and a reversible (RR = 1.8, 95% CI 1.1 to 2.9) or a fixed perfusion defect (RR = 2.9, 95% CI 1.6 to 5.4).(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise technetium-99m myocardial tomography for the risk stratification of men with medically treated unstable angina pectoris.

The prognostic value of predischarge maximal exercise stress testing with technetium-99m sestamibi (MIBI) myocardial tomography was assessed in 126 consecutive men hospitalized with a diagnosis of unstable angina pectoris who were medically stabilized. None had coronary revascularization for < or = 6 months after testing. Over a mean follow-up of 12 +/- 7 months (range 1 to 29), 35 patients (28%) had a cardiac event--nonfatal acute myocardial infarction (n = 6), cardiac death (n = 5), or rehospitalization for unstable angina (n = 24). Any type of cardiac event occurred in 12% of patients with normal MIBI scans, compared with 39% of those with an abnormal MIBI scan (p < 0.001) and 60% of those with a reversible perfusion defect (p < 0.0001). Only 2% of patients with normal scans had either a nonfatal myocardial infarction or cardiac death, compared with 14% of those with abnormal MIBI scans (p < 0.05) and 25% with a reversible defect (p < 0.001). A fixed perfusion defect was not associated with increased cardiac risk. With use of multivariable Cox proportional-hazards modeling, the only scintigraphic variable with independent predictive value was the presence of a reversible MIBI defect, with a relative risk of 3.8 (95% confidence interval 1.6 to 8.6, p < 0.05) for any cardiac event, and 19.2 (95% confidence interval 2.2 to 167.0, p < 0.05) for a nonfatal myocardial infarction or cardiac death. Cardiac event-free survival was also significantly decreased in patients with a reversible perfusion defect (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)