Out-of-hospital automatic cardioversion of ventricular tachycardia

A 42 year old man who survived sudden cardiac death was treated with an automatic implantable cardioverter/defibrillator. After a 5 month symptom-free interval, the patient received two internal discharges in the conscious state while wearing an ambulatory electrocardiographic recorder. Analysis of the tape revealed that both discharges were activated by two bursts of polymorphous ventricular tachycardia, the first one occurring at the end and the second at the onset of episodes of slow, hemodynamically stable monomorphous ventricular tachycardia. This case illustrates the reliability of the automatic implantable cardioverter/defibrillator as an antiventricular tachycardia device and the problem posed by its exposure to nonsustained ventricular tachycardia.

Paroxysmal fascicular tachycardia: electrophysiologic characteristics and treatment by catheter ablation

A 69 year old man with ischemic heart disease underwent electrophysiologic evaluation for paroxysmal wide QRS tachycardia, the configuration of which was identical to that recorded during sinus rhythm, that is, right bundle branch block, left anterior fascicular block and anterior myocardial infarction. Electrocardiographic recordings during tachycardia showed atrioventricular dissociation and His bundle activation occurring 5 ms after the onset of the QRS complex recorded on the surface electrocardiogram, consistent with a left posterior fascicular tachycardia. All traditional therapeutic attempts failed to prevent frequent recurrences of tachycardia, which was finally ablated by three 300 J shocks delivered through an electrode catheter positioned in the posterobasal region of the left ventricular septum.

A natural course of a dislocated healed tuberculous hip in a child. A case report

Subluxation was once a common complication of the tuberculous hip, even when properly treated. A review of the English literature failed to disclose the corrective process of development of the hip joint following a debridement operation. A three-year-old boy having a proven tuberculous hip had his hip dislocated after joint debridement. In the ensuing ten years, the luxated head spontaneously reduced to nearly normal position. Transitory capsular laxity was believed to cause the dislocation in this case, while growth and development led to spontaneous reduction. A decade may elapse before relocation is complete.

Ethnic elders and American health care--a physician's perspective

The aging process is a fugue composed of innumerable themes; the theme of "ethnicity" is by far one of its more dominant. Due to the increasing incidence of chronic, progressive infirmity and acute, catastrophic illness, the elderly are thrust into direct contact with the health care systems of their society. The experiences of ethnic elders in American health care situations are fraught with conflict and mutual dissatisfaction with the physician-patient relationship. Both providers and consumers of health care services harbor differing culture-bound perceptions of health, illness and the healing process; these cultural beliefs define personal and professional needs and expectations and notions of how those needs are to be met by others. Both physicians and patients can enhance their communication and their compassion for one another by acknowledgment of cultural differences and by increased willingness to interpret motives and behavior within native context.It behooves us in medicine to examine the cultural traditions underlying our own attitudes, beliefs and values about the aged in a universal sense, as well as in a culturally specific sense, that we may gain insight that will be helpful in serving elderly persons more effectively, and in solving some of the problems inherent in the aging process.

Small-angle neutron scattering study of Bence-Jones protein Mcg: comparison of structures in solution and in crystal

Immunoglobulins fragments are composed of globular domains linked by extended polypeptide segments. The molecular flexibility inherent in this arrangement allows for significant potential differences between structures observed in the crystalline state and those attained in solution. Small-angle neutron scattering measurements in dilute solution were performed on the Mcg Bence-Jones protein dimer, for which performed on the Mcg Bence-Jones protein dimer, for which accurate atomic coordinates have been determined by crystallographic methods [Edmundson, A. B., Ely, K. R., Abola, E. E., Schiffer, M., & Panagiotopoulos, N. (1975) Biochemistry 14, 3953-3961; Schiffer, M. (1980) Biophys. J. 32, 230-232]. The measured radius of gyration (Rg) in H2O buffer is 24.0 +/- 0.4 A and in D2O buffer is 23.3 +/- 0.1 A; the calculated value of Rv (Rg in vacuo) is 24.0 A. The above values compare well with the calculated Rg value of 23.6 A when refined coordinates of the trigonal crystal form of the Mcg Bence-Jones protein are used. On the basis of a match point of 44.2% D2O concentration, the experimental partial specific volume is 0.74 cm3/g. The experimentally derived molecular weight of 47 000 is in very good agreement with that (45 500) calculated from the amino acid composition. For comparison with different Fab's (antigen binding fragments) exhibiting various "elbow bends" due to the flexibility of the switch peptide between variable and constant domains of the immunoglobulin chains, calculation of the Rg value of the Mcg dimer was performed as a function of the elbow bend. The Rg varied from 22.8 to 26.0 A as the elbow bend was opened from 100 degrees to 180 degrees; the maximum radius of gyration of the particle was 26.5 A with the switch peptide stretched by separating the variable and constant domains by an additional 1.5 A at an elbow bend of 180 degrees.

Neonatal neurobehavioral tests following cesarean section under general and spinal anesthesia

The Scanlon Group of Early Neonatal Neurobehavioral Tests (E.N.N.S.) was administered to 150 babies delivered by elective cesarean section. Fifty of the mothers were induced into general anesthesia with thiopental, 4 mg. per kilogram, and 50 with ketamine, 1 mg. per kilogram. Fifty mothers received spinal anesthesia with 6 to 8 mg. of tetracaine. All mothers receiving spinal anesthesia were given 100 per cent oxygen by a transparent face mask and all undergoing general anesthesia received N2O-O2 (6L:6L) until delivery of the baby. All mothers were healthy and all babies weighed 2,500 grams or more, were apparently normal, and had Apgar scores of 7 or more at one minute to 10 at five minutes. Spinal anesthesia was associated with the greatest percentage of high scores on both the first and second day for overall assessment, pinprick response, tone, rooting, sucking. Moro response, placing, alertness, and total decrement (habituation) scores. There was a statistically significant difference between all the scores for spinal compared to the other two groups. The scores were lowest following a thiopental induction and intermediate with ketamine although the difference did not reach statistical significance.

Neonatal neurobehabioral tests following vaginal delivery under ketamine, thiopental, and extradural anesthesia

Scanlon's neurobehavioral tests were administered to 274 neonates on the 1st and 2nd days of life. Ketamine-N2O anesthesia had been given to 45 mothers, thiopental-N2O to 52, and lumbar extradural anesthesia with chloroprocaine to 177. All babies delivered from mothers receiving meperidine within 5 hours of delivery were excluded. All babies tested were over 2500 grams in weight, apparently normal, and with Apgar scores of at least 8 at 1 minute and 10 at 5 minutes. All were delivered from healthy women aged 18 to 35 years following a normal labor. Lumbar extradural anesthesia was associated with the greatest percentage of high scores on both the 1st and 2nd days for overall assessment, tone, rooting, sucking, Moro's response, placing, alertness, and habituation to pinprick. The scores were lowest after thiopental and intermediate following ketamine. No relationship was found between neurobehavior and low-forceps extraction, oxytocin augmentation, parity, or duration of labor.