Spinal arteriovenous malformation

The authors discuss a patient with a large (15 x 10 x 12 cm), bony soft tissue intradural arteriovenous malformation (AVM) who presented with a 20-year history of back pain. Plain radiographs revealed a destructive lesion. Magnetic resonance imaging showed serpentine vascular structures within the thecal sac and lytic bone lesions with multiple level involvement. A Craig needle biopsy by the referring physician, as well as an open biopsy by the authors, caused severe bleeding. There was no evidence of neoplasm. Selective spinal angiography demonstrated a metameric juvenile type AVM whose intradural component was fed by the artery of Adamkiewicz. Because the patient had no neurological deficit on presentation, the options of embolization and then surgery were considered too risky. The patient is being followed conservatively.

An 18-year-old with acute testicular pain. Torsion of the testicle

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Balloon angioplasty of stenosed Blalock-Taussig anastomosis: role of balloon-on-a-wire in dilating occluded shunts

Six children with cyanotic congenital heart defects, aged 6 to 60 months, underwent percutaneous balloon angioplasty of a narrowed Blalock-Taussig (BT) shunt to improve arterial oxygen saturation. The indication for angioplasty was a cyanotic heart defect not amenable to total surgical correction, either because of the age and size at presentation or because of anatomic complexity, but at the same time requiring palliation of pulmonary oligemia. Following balloon angioplasty, there was an increase in arterial oxygen saturation from 71 +/- 8% to 81 +/- 6% (p less than 0.05). In one child with long segment narrowing, there was no significant improvement in oxygen saturation, and this child underwent an additional BT shunt on the contralateral side. On follow-up 3 to 12 months after balloon angioplasty, the oxygen saturations remained improved (78 +/- 10%) in the remaining five patients. In two children with either complete or almost complete blockage of the BT shunt, we were unable to advance any catheter across the shunt but we were able to advance a 2 or 3 mm balloon on a wire and dilate the shunt, followed by introduction of a catheter carrying a larger balloon for angioplasty. This has permitted us to obtain the pulmonary artery pressure directly (this information was of obvious value in patient management) and resulted in an improvement in the arterial oxygen saturation. It is concluded that (1) balloon angioplasty of narrowed BT shunts is feasible, effective, and safe and (2) even completely occluded shunts can be cannulated and the balloon dilated with the newly available balloon-on-wire devices.

Impact of the Medicare fee schedule on payments to physicians

Beginning in 1992, the Medicare program will pay physicians by the Medicare Fee Schedule, a system of geographically adjusted standardized payment rates based in part on the Resource-Based Relative Value Scale developed by Hsaio et al and in part on current Medicare payments. In our simulations of the Medicare Fee Schedule, we find that (1) redistributions of Medicare-allowed charges across specialities will be substantial but approximately only half the size projected by Hsaio, (2) there will be large redistributions among geographic areas that tend to compound the specialty redistributions, and (3) there will be wide variation within specialties as to how individual providers are affected. The majority of the redistributive impact of the Medicare Fee Schedule is attributable to implementation of a geographically adjusted system of standardized payments rather than to the particular work values developed by Hsiao et al in the Resource-Based Relative Value Scale.

A 36-year-old woman with a pulsatile mass of the left tympanic membrane

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Left hilar mass without pulmonary disease. Pulmonary artery aneurysm

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Osteocartilaginous tumors in the parapharyngeal space arising from bone exostoses

Three osteocartilaginous tumors that arose from bone stalks were diagnosed by the demonstration, on multiplanar cross-sectional CT and MR images, of the site of stalk attachment to the adjacent mandible (one), skull base (one), and cervical vertebra (one). All three patients presented with signs and symptoms related to mass effect in the parapharyngeal region. Mass effect was more pronounced in the two cases of malignant degeneration (osteosarcoma, chondrosarcoma) than in the single case of benign osteocartilaginous exostosis. Differentiation of benign from malignant osteocartilaginous tumor may be accomplished by appreciating characteristic CT and MR features of the cartilage cap. The differential diagnosis of mass lesions of the parapharyngeal space should include tumors of osteocartilaginous origin.

Intermediate-term follow-up results of balloon aortic valvuloplasty in infants and children with special reference to causes of restenosis

Sixteen infants and children with valvular aortic stenosis underwent percutaneous balloon aortic valvuloplasty over a 36-month period ending August 1988. The mean systolic pressure gradient across the aortic valve decreased from 72 +/- 21 (mean +/- standard deviation) to 28 +/- 13 mm Hg (p less than 0.001) immediately after valvuloplasty; the degree of aortic insufficiency did not significantly increase. Follow-up catheterization (in 10 patients) and Doppler data (in all 16 patients) were available 3 to 32 months (mean 12 months) after valvuloplasty and revealed a residual aortic valvular gradient of 37 +/- 23 mm Hg, which continues to be significantly lower (p less than 0.001) than that before valvuloplasty. There was no increase in aortic insufficiency. On the basis of follow-up data, the 16 children were divided into 2 groups: group I with good results (gradients less than or equal to 49 mm Hg), 12 patients; and group II with poor results (gradients greater than or equal to 50 mm Hg), 4 patients. All 4 patients in group II required repeat balloon valvuloplasty or surgical valvotomy; none from group I required these procedures. Seventeen general, anatomic, physiologic and technical variables were examined by a multivariate logistic regression analysis to identify factors associated with restenosis; these risk factors were: age less than or equal to 3 years; and immediate aortic valvular gradient after valvuloplasty greater than or equal to 30 mm Hg. The immediate and intermediate-term follow-up results of balloon aortic valvuloplasty are encouraging. Recognition of the risk factors may help identify potential candidates for recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

An 80-year-old man with acute abdominal pain. Small bowel obstruction due to midgut volvulus

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[Primary severe neonatal hyperparathyroidism. Significance of genetic study and emergency parathyroidectomy]

Primary hyperparathyroidism in the newborn is uncommon. The clinical features as well as histological lesions of the parathyroid glands are quite different from those in the adult. The degree of hypercalcemia and the high frequency of pulmonary complications may threaten the life of the infant. Management is straight forward: early surgical removal and supplementation with calcium and vitamins should be quickly followed by an autograft. In the severe case herein reported, the diagnosis, suggested by family history, was confirmed by a rapid increase in calcemia as well as by very characteristic skeletal lesions.

Developing an AIDS prevention education program for persons with developmental disabilities

The AIDS epidemic poses a serious threat to people with developmental disabilities, the magnitude of which has not yet been fully realized by many professionals working with this population. Models for effective AIDS prevention education have been developed, however, within other populations. Key principles utilized in existing models were discussed and recommendations presented on how to adapt these models when designing programs for people who have developmental disabilities, most specifically, those in the mild/moderate range of mental retardation.

Radiologic case. Fibroadenoma of the breast

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Who benefits most from respite care?

This study examines the effect of five measures of utilization of respite care services (desire to use respite care services, actual use, accessibility, scheduling and helpfulness) upon mothers' coping resources. Using the analysis of variance between utilization measures and coping resources with the following intervening variables as covariates--mothers' self-esteem, family cohesion and adaptation, and clients' and mothers' characteristics--it was found that respite care acts as a differential service that can enhance coping resources (i.e., stress reduction skills) and is of most benefit to high self-esteem mothers of young developmentally disabled children. A home-based model was found to be the most beneficial to mothers in terms of enhanced coping resources. Findings are interpreted with respect to their implications for research, program model, planning and intervention.

Value of laser-assisted angioplasty in the community hospital

The experience with laser-assisted angioplasty at a community hospital was reviewed. One hundred twenty patients required angioplasty during a 7-month period, and in only 17-13 of whom had superficial femoral artery occlusions--was the use of lasers deemed appropriate. The success rate was 65% for laser-assisted angioplasty and 98% for balloon angioplasty. Laser-assisted angioplasty was the initial intervention in eight of the 13 superficial femoral artery occlusions. In two cases, a wire had been first advanced across the lesion, and in three cases, attempts to cross the lesion with a wire had been unsuccessful. The availability of the laser did not significantly increase the number of cases amenable to angioplasty, and at present laser angioplasty, does not seem to be cost-effective for community hospitals.

A young woman with vague lower abdominal pain. Benign cystic teratoma (dermoid cyst)

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Blurred vision and headaches in a patient positive for HBsAg

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Direct catheter redirection of a symptomatic errant intracranial Silastic sphere embolus

A patient with an arteriovenous malformation experienced a severe neurologic deficit during preoperative particulate embolization with Silastic spheres. Angiography and radiography showed that one sphere had become lodged in a normal branch of the middle cerebral artery. After several unsuccessful attempts at dislodgment, a Tracker catheter system was advanced directly to the site of the sphere, and the sphere was successfully dislodged. The neurologic deficit cleared immediately, and the sphere was redirected to an artery feeding the malformation.

Pelvic fullness, urgency and frequency following lymphadenectomy. Pelvic lymphocele

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Double vision in a patient with lymphoma

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The causes and underlying developmental mechanisms of congenital cardiovascular malformations: a critical review

Cardiovascular malformations are the second most common type of birth defect, occurring in 5-8/1,000 livebirths with a still higher prevalence among stillborn infants and spontaneously aborted embryos and fetuses. Dealing effectively with the high frequency of heart defects means reducing the incidence of cardiac malformations in the world. In this paper we cite some of the genetic and environmental risk factors associated with congenital cardiovascular malformations, describe the putative biochemical nature of the genetic predisposition relative to environmentally induced teratogenesis, and either support or discourage the use of available methods as strategies in preventing cardiovascular anomalies.

Aortico-left ventricular tunnel: diagnosis based on two-dimensional echocardiography, color flow Doppler imaging, and magnetic resonance imaging

Aortico-left ventricular tunnel is a rare congenital cardiac lesion that often results in severe aortic insufficiency in infancy. In previously reported cases, the diagnosis has often been missed initially despite use of cardiac catheterization and angiography. We describe a patient who underwent successful surgical correction of this malformation at 10 months of age after the diagnosis had been established by use of two-dimensional echocardiography, color flow Doppler imaging, and magnetic resonance imaging. Aortico-left ventricular tunnel can be diagnosed by use of these noninvasive means without cardiac catheterization.

Right upper quadrant pain

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Clinical aspects and treatment of rapid cycling mood disorders

Eight female patients with rapid cycling mood disorders (at least four discrete affective episodes per year) were examined from a clinical perspective. Assessment suggested several different etiologies to the rapid cycling pattern in these patients. These included that the rapid mood swings were: a natural expression of the affective disorder, tricyclic induced, a result of frequent medication changes and/or poor medication compliance, and a combination of the aforementioned etiologies. All patients were helped significantly with treatment. Treatment was individualized for each patient's unique illness and possible etiological factors in the rapid cycling. Treatment strategies and guidelines include: A psychotherapeutic approach involving the patient and his family which emphasizes the lengthy nature of treatment before expected results; The necessity of rigorous drug adherence, The sole use of "high dose" lithium therapy (greater than 1.2 MEQ/L) in some patients, and the consideration of "high dose" lithium in conjunction with tricyclics, MAO inhibitors or "adjuvant" medication in certain bipolar II patients; The discontinuation of tricyclics in bipolar rapid cyclers; The combination of lithium salts and carbamazepine or the use of carbamazepine alone in selected patients.

Neonatal primary hyperparathyroidism: total parathyroidectomy with autotransplantation of cryopreserved parathyroid tissue

Primary neonatal hyperparathyroidism is a life threatening disease because of severe hypercalcemia. The best therapy is early total parathyroidectomy which requires permanent replacement therapy. We describe the first case treated by total parathyroidectomy and late autotransplantation of cryopreserved parathyroid tissue. Twenty months after transplantation, serum calcium and phosphate levels are normal in the absence of any supplementary treatment.

Venous "lakes" of the hands

Following pharmacologic vasodilatation, multiple vascular "lakes" were observed on angiograms of the hand in 55 patients. Most had no history of vascular anomalies or disease. The authors believe that these lakes are venous structures and that their filling is a physiologic phenomenon.

Digital subtraction angiography in the community hospital

Although digital angiography may involve the same physician processes in the university as in the community hospital, it can be seen that the indications, approaches, and utility of DSA are somewhat different in the two environments. DSA is presently in a state of change, in part because of the maturing of other modalities and also because of the present emphasis on cost-saving in medical imaging. As referring physicians become used to digital arteriographic images, more and more procedures will be performed with DSA. We believe the DSA will have an important role in the community hospital for years to come. Its emergence as the first of the "conventional" imaging techniques to be digitized can be seen as an initial step toward the total digital imaging department of the future.

[Isolated renal aspergillosis in a leukemic boy]

The authors described a 6 years old boy suffering from acute lymphoblastic leukemia and treated by the B.F.M. protocol who presented during intensive chemotherapy period a aspergillus renal abscess apparently unique. During the postoperative period the evolution was progressively favorable under prolonged anti-fungal treatment. The different clinical features, the non facilities of diagnosis and the mean possibility of treatment in aspergillus infection in immunodeficient patients are reviewed.