The sensitivity of the Bender-Gestalt Test as a screening instrument for neuropsychological impairment in older adults

We investigated the sensitivity of the Bender (1938) Visual-Motor Gestalt Test (BGT) using the Halstead-Reitan Neuropsychological Battery (HRB) as the criterion for cortical dysfunction. We studied 95 subjects over age 55 who had been diagnosed as having dementia or pseudodementia. Subjects were classified as mild, moderately, or severely impaired on the HRB and as impaired or unimpaired on the BGT. The results indicated that the BGT is less sensitive (36%) than was expected when used on an impaired geriatric population. The data further indicated that false negatives occurred more frequently with the BGT when individuals had mild neuropsychological impairment. Less frequent misclassifications occurred as the severity of impairment on HRB indices increased.

Presentation of undiagnosed pheochromocytoma during coronary artery bypass surgery

Hypertension and tachyarrhythmias arising during an operative procedure are rarely caused by an unsuspected pheochromocytoma. However, when this tumor becomes clinically manifest under general anesthesia during a procedure for an unrelated condition, the mortality is high. An unusual case of a patient who developed episodes of catastrophic hypertension and tachyarrhythmias while undergoing a coronary artery bypass procedure is described. The subject of undiagnosed pheochromocytoma becoming clinically manifest under general anesthesia is discussed with a pertinent review of the literature.

Correlation of 31P nuclear magnetic resonance chemical shifts in aryl phosphinates with Hammett substituent constants: Inductive versus resonance interactions and relevance to pπ–dπ bonding

Substituent-induced chemical shifts and coupling constants in the 31P, 13C, and 1H nuclear magnetic resonance spectra of meta- and para-substituted phenyl dimethylphosphinates (1), methylphenylphosphinates (2), and diphenylphosphinates (3) have been determined in CDCl3 solvent. For all three series, a correlation of δ 31P with Hammett–Taft σ0 (or σ) constants is preferred over σ− on the basis of the correlation coefficient and standard deviations of the slope and intercept values. Electron-withdrawing substituents induce downfield shifts in δ 31P, in contrast to the inverse trends observed for structurally related series of oxyphosphorus acids and their derivatives. It is proposed that electron-withdrawing substituents act to deplete the electron density on the aryl oxygen, thereby weakening a pπ–dπ bonding interaction between the aryl oxygen and phosphorus. The resultants loss of d-orbital density on phosphorus causes a downfield shift in δ 31P in each of the phosphinate series. Phenyl substituents attached directly to phosphorus in series 2 and 3 increase the phosphoryl pπ–dπ back-bonding interactions, either through inductive or resonance effects, which leads to shielding of the phosphorus atom, overriding the anticipated downfield shift through inductive electron withdrawal of the phenyl substituents in series 2 and 3, relative to the methyls in series 1. Trends in Hammett ρ values for the plots of δ 31P and δ 13C versus σ0 and differences in the shielding of 13C and 1H nuclei of the methyl attached to phosphorus in series 1 and 2 suggest that the phenyl groups may interact in π bonding with the phosphorus atom through a resonance interaction.

Prosthetic replacement surgery for cervical spine metastasis

Since 1972, 18 patients suffering from metastatic cancer in the cervical spine were treated with prosthetic replacement surgery. The surgery enabled the authors to decompress the spinal cord and the nerve roots and at the same time restore stability in the affected spine. Patients suffering from severe pain and spinal cord and/or nerve root compression secondary to involvement of a single vertebral body particularly benefited from this surgery. The rates of positive recovery were as follows: 94.1% for pain relief, 91.7% for motor recovery, and 87.5% for ambulation. The surgical efficacy was maintained until the terminal stage. Tumor recurrence took place in five cases--two anterior, and three posterior. Anterior recurrence caused a marked instability, whereas posterior recurrence did not affect stability.

Concomitant cerebral and myocardial revascularization

Patients who present with concomitant coronary artery disease and hemodynamically significant carotid artery occlusive disease represent a subset of individuals at high risk for myocardial infarction and stroke. Whether the combined surgical approach favorably influences the outcome of patients requiring major cardiovascular surgical procedures remains controversial. However, it is clear that coronary artery bypass procedure and carotid endarterectomy are each beneficial to patients who have the appropriate indications for each procedure individually. The coincidence of carotid and coronary occlusive disease varies with the type of diagnostic tests involved. Angiographic data suggest a coincidence in the range of 1 to 6 per cent, while vascular laboratory screening data in some studies have indicated a coincidence as high as 12 to 14 per cent--a range that appears to be higher than one might expect from clinical experience. It is clear from analyzing the patient profile of this subset of patients from large clinical reviews that in general they are older and sicker and have a higher incidence of cardiovascular risk factors representing more extensive atherosclerosis. It is also well documented that the neurologic complication rate for all patients undergoing coronary bypass is in the range of 2 per cent. Therefore, it should not be expected that the operative mortality rate and risk of perioperative stroke in patients undergoing the combined reconstructive procedure can equal those for either procedure alone. These patients represent a separate clinical subset at higher risk for perioperative complications and need to be evaluated individually.

The cost of simultaneous surgical standby for percutaneous transluminal coronary angioplasty

From November, 1980, to May 1985, 699 patients have undergone percutaneous transluminal coronary angioplasty of 784 lesions at our institutions. Simultaneous surgical standby was available on all cases. One hundred twenty-four patients (18%) underwent immediate myocardial revascularization; 45 (6%) were operated on because the lesion could not be dilated. Seventy-nine patients (11%) underwent immediate operation for an acute complication of angioplasty: coronary occlusion in 45, dissection in 29, coronary perforation in three, and atrial perforation in one. Fourteen patients (18%) required cardiopulmonary resuscitation en route to the operating room, and 10 patients (20%) had insertion of an intra-aortic balloon pump in the cardiac catheterization laboratory. The average time from complication to reperfusion was 87 minutes, ranging from 40 to 165 minutes. An average of 2.0 grafts per patient (ranging from one to five grafts per patient) were performed. Of those 79 patients who underwent operation for an acute complication, one died (1.3%), 31 patients (39%) had a myocardial infarction according to enzyme criteria (creatine kinase-myocardial band greater than 40 IU), and 17 patients (22%) had new Q waves on the electrocardiogram. Good results are related to minimizing the time the myocardium is ischemic. No patient in whom reperfusion was begun in less than 75 minutes had a Q wave infarction or a creatine kinase-myocardial band level greater than 40 IU. Simultaneous surgical standby is the only method allowing immediate access to surgical facilities. A standby team of eight persons and equipment were immediately available for emergency bypass grafting for an average of 3.6 hours (range 1.3 to 5.4 hours per angioplasty attempt). The patient charges for this simultaneous standby were $632.00 per angioplasty attempt, or $442,278.00 for the entire series. The actual cost of the standby was over $1,700.00 per attempt totaling $1,188,843.00 for the 699 patients. This underestimation of the cost of surgical standby has occurred in other series, because little mention has been made of this cost in the published reports on the cost effectiveness of angioplasty. In terms of time demands, over 2,500 hours were spent by surgeons standing by for the 699 attempts. Simultaneous surgical standby is the most effective means of limiting the time the myocardium is ischemic after an angioplasty complication. However, this method is costly, necessitating more of a financial and time commitment than generally anticipated. Future studies of the cost effectiveness of angioplasty should include the cost of surgical standby with accurate per-patient cost accountability.

Surgery of left atrial myxomas. Report of eleven cases and review of the literature

Eleven patients with left atrial myxoma in a ten-year period were reviewed. They ranged from 16 to 69 years old. Eight patients were female. All tumors were located in the left atrium; one patient had multiple tumors. The main clinical presentation was congestive heart failure seen in eight patients. Ten patients had a correct pre-operative diagnosis. Echocardiography confirmed the diagnosis in seven patients, angiocardiography in two and cardiac catheterization in one. All tumors were successfully removed with the aid of cardiopulmonary bypass and using a right atriotomy and trans-septal approach. Two patients underwent concomitant saphenous vein aortocoronary bypass. There were no operative deaths. Excision of the tumor resulted in marked symptomatic improvement. There have been no recurrences. A review of the pertinent literature is presented.

Parallel-form reliability of the Wechsler Memory Scale in a geriatric population with suspected dementia

The present study examined parallel-form reliability of the Wechsler Memory Scale (WMS) in a population where such forms are particularly useful, that is, among patients who are suspected of having some type of dementing illness. Comparative analyses were made for total raw scores. Memory Quotient (MQ) scores, and individual subtest scores. Thirty geriatric patients originally referred for neuropsychological testing because of suspected dementia were given both Forms 1 and 2 of the WMS. The results yielded high overall reliability coefficients for MQ and total raw scores. Individual subtest scores also yielded rather high coefficients, and only one subtest (Associate Learning) had a significant mean difference. Apparently, the two forms have sufficient parallel-form reliability to be considered clinically interchangeable. Thus, the WMS may be a useful tool for repeat evaluations of memory functioning in a demented population.

Coronary artery bypass surgery following thrombolytic therapy for acute coronary thrombosis

One hundred thirty-six patients underwent thrombolytic therapy for acute evolving myocardial infarction from June, 1981, through December, 1982. Of these patients, 51 underwent coronary bypass procedures from two hours to 90 days (average, 16 days) following thrombolytic therapy. Six (12%) had single-vessel disease, 15 (29%) had double-vessel disease, and 30 (59%) had triple-vessel involvement. Ejection fraction values ranged from 21 to 60%. The average number of grafts performed per patient was 3.4. There were no operative deaths in this series. Postoperative hemorrhagic problems were minimal, and the incidences were no different from those for other coronary bypass patients. In follow-up ranging from 2 to 18 months, there was no recurrence of severe angina or other clinical evidence of saphenous graft occlusion in the thrombolysed vessels. Of the 45 patients eligible to return to work, 40 (89%) have done so. The data from this series suggest that surgical myocardial revascularization after intracoronary thrombolytic infusion for acute myocardial infarction can be performed safely and that complete recovery and a high return-to-work ratio can be anticipated.

Yeast contains small nuclear RNAs encoded by single copy genes

We have identified a group of RNA molecules in Saccharomyces cerevisiae that appears to be equivalent to the U class of small nuclear RNAs previously described in other eucaryotes, resembling them in size, metabolic stability, 5' cap structure, presence of modified bases, and nuclear localization. However, the yeast snRNAs differ from their counterparts in several potentially important ways. First, they are present in very low abundance, less than 200 copies per cell, as compared to 10(5)-10(6) for mammalian U1-U6. Second, there appear to be more species in yeast than in any cell type previously examined. Finally, we have cloned five yeast snRNA genes, and find that each is present in a single copy per haploid genome, whereas all previously characterized snRNAs are encoded by multiple (5 to 100) gene copies. The presence of single copy genes in yeast will greatly facilitate the genetic analysis of snRNA function.

Alterations in pulmonary function following pneumonectomy for bronchogenic carcinoma

Twenty-one patients who underwent pneumonectomy for bronchogenic carcinoma at the Nashville Veterans Administration Hospital from November, 1977, to March, 1980, were evaluated with standard pulmonary function tests preoperatively and postoperatively. Twelve patients had Stage I disease, 4 patients had Stage II, and 5 patients had Stage III disease. The interval between the operative procedure and postoperative testing ranged from 2 to 33 months (mean, 12.4 months). Mean functional loss of pulmonary capacity after pneumonectomy was based on analysis of preoperative and postoperative forced vital capacity (FVC) and initial-second forced expiratory volume (FEV1) indices. The mean functional loss as expressed by FVC was 41.5% after right pneumonectomy and 34.0% after left pneumonectomy. The mean functional loss as expressed by FEV1 was 40.2% after right pneumonectomy and 38.3% after left pneumonectomy. The postoperative functional status of each patient was classified according to the New York Heart Association criteria. Nineteen of the 21 patients were in Class I or II preoperatively. Postoperatively, 10 patients were in Class I or II and 11 in Class III or IV. The results indicate that a postoperative FVC less than 2.5 liters and FEV1 less than 1.5 liters are not compatible with active life.

The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies

The authors have observed a series of patients with cervical monoradiculopathies due to extradural compressive disease in whom clinical signs included relief of radicular pain with abduction of the shoulder. Of 22 patients requiring myelography for unremitting radicular pain, 15 experienced relief of pain with shoulder abduction. Thirteen patients showing this sign required surgery and all achieved a good result. Two patients were relieved with additional conservative measures. Pain relief obtained with this maneuver seems to occur by decreasing tension on the nerve root. This shoulder abduction relief sign has not been commonly elicited in the past, and the authors wish to bring attention to its value as an indicator of significant cervical extradural radicular compressive disease.

Para-articular chondromas and osteochondromas: a report of three cases

Observations in 3 middle-aged patients demonstrate that solitary osteochondromas in para-articular locations can be confused with intrasynovial osteochondromatosis or osteochondromas arising from bone and extending into joint regions.

Parotid neoplasms: a report of 250 cases and review of the literature

A 25-year experience with parotid tumors was reviewed. From a total of 250 neoplasms, 173 were histologically benign and 77 were malignant. Benign mixed tumors accounted for 59% of all lesions. Clinical parameters used to diagnose parotid neoplasms were found to be unreliable in determining whether a given tumor was benign or malignant. The mean age for malignant lesions was 10 years greater than for benign lesions. The phenomenon of malignant transformation of a benign tumor was considered in four patients. Complete surgical excision is the safest and preferred method for diagnosis. Preoperative needle or incisional biopsy are associated with a high degree of local recurrence. The appropriate management of any parotid tumor is predicated on special histological type. Local excision or enucleation no longer have a place in the surgical management of benign parotid tumors. Postoperative tumor recurrence and morbidity are directly related to awareness of surgical anatomy and pursuit of correct surgical techniques for adequate resection. The five-year recurrence rate for 102 benign mixed tumors was 6%. Recurrence in malignant tumors varied with specific histological types but was generally high. Five-year survival for all malignant parotid tumors was 48%.

Pyogenic infections of the sacro-iliac joint

In 3 cases of pyogenic infection of the sacro-iliac joint, the diagnosis was difficult. Limp, buttock pain and upper sciatica were the most common presenting symptoms. Differential limitation of hip motion, positive straight leg raising, a positive Gaenslen test and pain on pelvic compression were frequent fingings. Increased E.S.R., W.B.C. count and fever were seen in 2/3 cases. Plain and tomographic X-rays are often helpful but bone scan has been helpful in localizing early lesions. Treatment after early diagnosis may consist of antibiotics and immobilization alone while in the more chronic cases surgical drainage and debridement may be necessary.

Ewing's sarcoma of the great toe. A case report

A case of Ewing's Sarcoma originating the great toe is reported. Because of the rarity of its appearance outside the pelvis and long tubular bones, Ewing's Sarcoma is often misdiagnosed when it occurs in the distal portion of the extremities. Ewing's Sarcoma may be difficult to distinguish from infection. Biopsy is recommended for any indolent or refractory lesions presumed to be infectious. Bone scanning with Technetium Polyphosphate is a useful tool for diagnosis and evaluation of this tumor. Vigorous integrated chemotherapy and radiotherapy had little effect in this patient with metastatic disease.

Lateral collateral ligament ankle injuries in young athletic individuals

1. Eleven cases of surgical repair of acute tears of the capsule, anterior talo-fibular, and calcaneo-fibular ligaments of the ankle in young athletic individuals are reported. 2. Diagnosis was made by clinical examination and stress X-rays and confirmed by arthrography in selected cases. All of the ligament ruptures were visualized at surgery. 3. Post-surgery, all of the patients had a stable ankle and were able to return to vigorous athletic endeavors without disability. 4. This study lends support to the impression that surgical repair of severe lateral collateral ankle ligament injuries in young athletic individuals leads to a functionally and mechanically stable ankle able to withstand severe stress without disability.

A simple vacuum cassette for microradiography

Microradiography has been found to be a useful research tool for the investigation of bone formation, resorption and mineralization. Since relatively thin (60-125 mum) embedded hard tissue sections are used for this procedure, great care must be taken to ensure that the specimen is placed firmly and flatly without buckling against the photographic emulsion during the period of x-ray exposure in order to avoid distortion in the final microradiograph. The construction and use of a simple and inexpensive vacuum cassette for this purpose is described. With the use of a portable vacuum reservoir, specimen mounting can be done in a darkroom some distance from the x-ray source, often permitting the use of already existing x-ray facilities in other laboratories.