Human chorionic gonadotropin rise in normal and vanishing twin pregnancies

OBJECTIVE

The purpose of the study was to describe and to compare the rate of rise of human chorionic gonadotropin (hCG) in vanishing twin and normally progressing twin pregnancies during the first trimester.

DESIGN

All patients with twin pregnancies between 1985 and 1989 were prospectively studied. Human chorionic gonadotropin was measured one to three times per week between days 12 and 52 after luteinizing hormone (LH) surge or day of hCG administration (day 0). Pelvic ultrasound (US) was performed weekly beginning on day 24.

SETTING

The study was performed at Rush-Presbyterian-St. Luke's Medical Center in an academic private practice setting of the Section of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology.

PATIENTS

Forty patients who conceived after treatment of infertility and who had two gestational sacs on US examination were included in the study after the following criteria were met: (1) both sacs progressed to exhibit a fetal pole and (2) day of LH surge and/or day of hCG administration was known.

MAIN OUTCOME MEASURE

The rate of rise of hCG was slower in vanishing twin pregnancies than in normally progressing twin gestations for the entire time period studied (P less than 0.05).

RESULTS

A vanishing twin occurred in one third of the twin pregnancies. Forty-six percent of these losses occurred after fetal heart activity had been established.

CONCLUSIONS

Vanishing twin phenomenon occurred in a large proportion of twin pregnancies in this infertility population. Fetal heart activity was not a reliable predictor of continuing fetal viability in early twin gestations. Vanishing twin conceptions were characterized by a slower rate of rise of hCG than normally progressing twin pregnancies.

Coping with an ileostomy

This paper reports the results of a study of persons who had undergone surgery to cure the disease ulcerative colitis. All subjects had had their colon removed and were left with an incontinent surgically constructed anus on their abdomen, called an ileostomy. The ways in which ex-patients cope with some of the consequences of surgery are described. The data were collected using semi-structured interviews, which were analysed qualitatively.

Assessment of prediction of mortality by using the APACHE II scoring system in intensive-care units;

Some investigators have suggested that information on quality of care in intensive-care units (ICUs) may be inferred from mortality rates. Specifically, the ratio of actual to predicted hospital mortality (A/P) has been proposed as a valid measure for comparing ICU outcomes when predicted mortality has been derived from data collected during the first 24 hours of ICU therapy with use of a severity scoring tool, APACHE II (acute physiology and chronic health evaluation). We present a comparison of mortality ratios (A/P) in four ICUs under common management, in two hospitals within a single institution. Significant differences in A/P were detected for nonoperative patients (0.99 versus 0.67;P = 0.014) between the two hospitals. This variation was traced to uneven representation of a subset of patients who had chronic health problems related to diseases that necessitated admission to the hematology-oncology or hepatology service. No differences in A/P were seen between the two hospitals for operative patients or for nonoperative patients on services other than hematology-oncology or hepatology. Thus, differences in A/P detected by using the APACHE II system not only may reside in operational factors within the ICU organization but also may be related to weaknesses in the APACHE II model to measure factors intrinsic to the disease process in some patients. We suggest that case-mix must be examined in detail before concluding that differences in A/P are caused by differences in quality of care.

Respiratory failure due to choriocarcinoma: a study of 103 dyspneic patients

Treatment of choriocarcinoma is mostly successful but there is still appreciable mortality from early respiratory failure. A series of 135 patients with choriocarcinoma presenting with dyspnea between 1960 and 1988 was studied to find prognostic factors for early respiratory death and to identify how mortality may be further reduced. Mortality with respect to early respiratory death (ERD) was 11% and was significantly associated with WHO prognostic score, chest X-ray appearance, central cyanosis, tachycardia, anemia, and clinical evidence of pulmonary hypertension. Indicators on chest X ray of high risk of ERD were the presence of more than 10 opacities, extensive opacification of lung fields, size of metastases, and hazy background obscuring the vascular pattern. Intensity of initial treatment was not correlated with this outcome. A set of criteria has been derived which will predict ERD with 100% sensitivity and 38% positive predictive value. These are opacification of lung fields on chest X ray of more than 50%, OR initial plasma hCG level greater than 10(5) when there is anemia and a history of chest pain. Patients presenting with choriocarcinoma and dyspnea who fulfill these criteria should be considered for extracorporeal perfusion techniques. As respiratory failure in this condition is characterized by hypoxemia and right-to-left shunting, extracorporeal perfusion should be effective. Ventilation should be avoided as no patient survived mechanical ventilation.

Behavioural change and the stress-coping paradigm: some comments on modelling the European code on avoiding cancer

The Europe Against Cancer Campaign's ten-point code is considered. The difficulties involved in conceptualizing an extremely diverse set of behaviours are highlighted. A framework for modelling the code, based upon the stress-coping paradigm, is presented.

The head-injured outpatient: presentations and rehabilitation

Head injury, which annually affects 154 per 100,000 persons in Maryland, is a serious problem requiring attention from the medical community. The role of the general practitioner is viewed as central to the process of rehabilitation since this medical professional has a pre-existent relationship with the patient and the family.

Biological degradation of 2,4-dichlorophenoxyacetic acid: chloride mass balance in stirred tank reactors

A mass balance was developed for the degradation of 2,4-dichlorophenoxyacetic acid by a mixed culture. Batch culture experiments showed the degradation to be an acid-producing step. Inorganic chloride concentration consistently correlated with the expected value and with base consumption to maintain a constant pH.

Effects of lesion laterality on the Satz-Mogel WAIS-R short form

Effects of lateralized brain damage on the Satz-Mogel (1962) WAIS-R short form were examined. Patients (N = 65) were assigned to groups based on diffuse, predominantly left, or predominantly right brain damage. Overall, results supported the validity of the Satz-Mogel short-form IQs with neurological patients, although there were significant ANOVA results for various subtests when original scores were compared to short-form scores. A comparison of groups in regard to the number of deviations (i.e., +/- 3) from original WAIS-R subtests raised questions with regard to the effects of lesion laterality on certain short-form subtest scores. Criteria for evaluating short forms and issues for further research are discussed.

Managing radical surgery: notes from the patient's viewpoint

Based on a diary which was kept while preparing for and undergoing pan-proctocolectomy, the paper describes the process of coming to terms with an ileostomy. A number of stages in the process are identified: anticipation, reorientation, trauma, maintenance of selfimage and accommodation. The social-psychological strategies for coping with the process are elaborated.

Anomia in cerebral diseases

Naming performance was studied in demented patients, age-matched controls, left-hemisphere stroke patients with aphasia and right-hemisphere stroke patients. The experimental naming test compared four levels of perceptual difficulty and two language variables: word frequency and word length. Naming accuracy and error types were compared among subject groups. Perceptual difficulty influenced naming in the demented and right-hemisphere stroke patients, but not in aphasics and controls. Visual errors, likewise, characterized the former two groups. Semantically-related errors and circumlocutions characterized the naming of aphasic and demented patients, while phonemic errors were common only in aphasics. The results suggested differing patterns of anomia in different patient groups.

Relationships among Wechsler intelligence and memory scale quotients in adult closed head injured patients

Correlations and discrepancy scores (Full Scale IQ minus Memory Quotient) among Wechsler intelligence and memory quotients were assessed in a sample of 126 closed head injured (CHI) adults. Results indicated a slight, generalized decrease in CHI patients' mean level of performance. A significant correlation of .76 was obtained between patients' IQ and MQ scores. Discrepancy scores were relatively smaller than those found in prior research and were influenced partially by the patient's age and by time of testing postinjury. The relative magnitude of discrepancy scores found in CHI is discussed in relationship to other groups of brain-injured patients.

The subjective experience of chronic disease: some implications for the management of ulcerative colitis

The paper first describes the subjective experience of chronic ulcerative colitis. Using autobiographical data some of the intra- and inter-personal strategies for coping with the disease are outlined. Then, selective socio-medical issues arising from the data--the relationships between physical and social events, denial and normalisation of illness, doctor-patient communications, and lay knowledge and perceptions--are elaborated. Finally suggestions for the social management of patients with ulcerative colitis are drawn out. It is argued that the importance of the subjective experience, as well as the physical process of the disease must be confronted by the physician, that the counseling of colitics should aim, where possible, to encourage normal social development, that the possibilities of the life-threatening nature of the disease and the type of curative surgery should be addressed at an early stage by the patient and their family and that patients should be allowed to do "grief-work" to help them to come to terms with the disease and its likely outcomes.

Loss and grief reactions as responses to surgery

Using autobiographical material, the patient experience of major surgery (panproctocolectomy and ileostomy) is described. A number of stages are identified in the patient experience: the development of dependence before surgery; disconnectedness from the social world immediately after surgery; and reality shock as grief and loss became apparent. The data are analysed using a theoretical perspective originally developed to describe reactions to bereavement. The practical nursing and counselling implications deriving from the theoretical model are elaborated.

Factitial aplastic anemia

A 29-year-old married nurse with pancytopenia was discovered to be surreptitiously ingesting alkylating agents. Despite her life-threatening behavior, there was no evidence that she was psychotic, depressed, or cognitively impaired. Psychological testing was indicative of a sociopathic personality. The patient and her behavior elicited considerable affect and controversy among members of her health team. It is hypothesized that the patient's behavior resulted from longstanding low self-esteem. The production of a dramatic illness gratified dependency needs and fooling physicians gave her a sense of power.

Wechsler Adult Intelligence Scale and Wechsler Adult Intelligence Scale-Revised in a neurologically impaired population

Compared Verbal, Performance, and Full Scale IQ scores from two groups of neurologically impaired patients (N = 114) similar in age, years of education, occupation, race, sex, and etiology and location of cerebral dysfunction. One group had been given the WAIS and the other the WAIS-R. All three IQ scores were higher for the WAIS group, with Full Scale and Verbal scores significantly (p less than .05) higher. Changes in item content and standardization sample cohort effects are offered as partial possible explanation for the results. The IQ scores from the two tests cannot be considered as interchangeable for neurological patients.

Language disturbance. An initial symptom of cortical degenerations and dementia

Six patients manifested progressive language disturbance, resembling aphasia secondary to a focal dominant hemisphere lesion, as either an isolated initial symptom or a prominent early feature of a more generalized dementing illness. None had a history of transient ischemic attacks or stroke, and in all cases an extensive clinical and laboratory investigation failed to show either a focal brain lesion or a definable etiology of dementia. This article discusses the relationship of isolated or early aphasia to known dementing syndromes. Patients who consult physicians for language disturbance should be evaluated and followed up both for evidence of progressive language deterioration and for the development of a generalized dementia.

The naming disorder of dementia

Naming impairment is a common feature of the language disorder of dementia, yet agreement has not been reached on its mechanisms. In this study, the confrontation naming performance of twelve demented subjects was compared to that of age-matched controls. Naming deficits were studied in relation to overall language and cognitive dysfunction and analysed to assess the importance of both perceptual and linguistic factors. Naming dysfunction occurred even in mild dementia, in patients whose overall language function remained normal, and worsened in proportion to the degree both of language deficit and overall cognitive dysfunction. Perceptual difficulty and word frequency, but not word length, were important determinants of naming performance in demented patients.

Chancers, pests and poor wee souls: problems of legitimation in psychiatric nursing

This paper explores the relationship between psychiatric nurses and 'problem' patients as a means of commenting on the occupation of psychiatric nursing. Proceeding from a detailed examination of the case of one particularly problematic female patient, and drawing on a body of observational and interview data relating mainly, though not exclusively, to nursing activity on two very different psychiatric wards, we argue that what is critical in determining nurses' categorization of some patients as 'problems' is not so much the level or nature of patients' demands, as much previous work has suggested, but rather the patient's willingness to legitimate the nurses' therapeutic aspirations. Possessing neither readily identifiable technical skills nor unambiguous authority, the psychiatric nurse must look to her dealings with patients to sustain a viable professional identity. 'Problem' patients are those who call attention to the fragility of nursing authority by rejecting, implicitly or explicitly, the special services that the psychiatric nurse stands ready to provide.

Facial recognition memory in dementia

Previous investigations of memory in senile dementia of the Alzheimer's type (SDAT) have focused on verbal learning and memory. The aim of the present study was to determine whether the amnesia of SDAT is limited to verbal material. Patients with SDAT (N = 29; mean age = 69.3) and healthy normal controls (N = 41; mean age = 69.3) were given a test of facial perception and two recognition memory tasks, one for words and one for faces. The results indicate that dementia patients show a deficit in the retention of facial information. This deficit cannot be attributed to faculty initial perception or to a response bias. The verbal and facial memory deficits in SDAT appear to differ: performance on tests of verbal and facial memory is relatively independent, and substantial encoding and linguistic defects contribute to the verbal, but not the facial, memory disorder resulting in more severe impairment on tests of verbal memory. The implications of these findings for research on the neuropharmacology and pathophysiology of SDAT are discussed.

Good and bad patients: a review of the literature and a theoretical critique

Nursing, sociological and psychological research into good and bad, popular and unpopular, and desirable and undesirable patients is reviewed. A number of themes which have been linked by researchers with the evaluation of good and bad patients are identified. These are patients' illnesses and diseases, patients' behaviour, the social backgrounds of patients, patients' attitudes and staff attitudes. It is argued that much of the literature on good and bad patients is deficient from an empirical, a methodological, an epistemological and a theoretical point of view. An alternative theoretical framework is suggested, using as its starting point an interactionist conception of the nursing role. It is suggested that patients come to be defined as good or bad not because of anything inherent in them or in their behaviour, but as a consequence of the interaction between staff and patients.

Carotid artery disease, carotid endarterectomy, and behavior

Thirty-five carotid endarterectomy patients and 17 peripheral vascular surgery controls were evaluated psychologically preoperatively and postoperatively. The endarterectomy sample was restricted to patients with transient ischemic attacks. Neuropsychological tests included measures of language, attention, memory, problem solving, and sensory and motor skills. Personality tests included measures of general psychopathology, with specific evaluation of anxiety and depression. Mean scores of the endarterectomy and control groups were not statistically significantly different preoperatively for any test. Postoperatively, only the endarterectomy group showed mean improvement on measures of memory and verbal fluency. Both groups showed improvement on several other neuropsychological measures, and in reduction in state anxiety and on another indicator of psychopathology. Endarterectomy patients whose cognition improved postoperatively were younger, better educated, and had lower admitting systolic blood pressure; they also tended to have a lesser incidence of generalized vascular disease.

Reversible mental symptoms in temporal arteritis

Mental symptoms are common in temporal arteritis. Reported here is a case in which a deficit in nonverbal memory documented with psychological testing resolved after a course of steroids. Besides the global confusional states commonly seen in temporal arteritis, focal intellectual impairment may be seen. It seems possible that some patients presenting with dementia as well as focal mental signs may have temporal arteritis. The diagnosis can easily be made by performing an erythrocyte sedimentation rate and temporal artery biopsy.