Damage awards to patients up 48% in 1989, CMPA reports

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Anomalies of human oocytes from infertile women undergoing treatment by in vitro fertilization

During in vitro fertilization treatment, three types of oocyte anomalies were observed in four infertile women. These anomalies were related to (1) failure of oocyte maturation from the germinal vesicle stage of meiosis, (2) failure of polar body formation and cleavage, and (3) absence of oocytes in otherwise mature follicular aspirates. These anomalies are considered to contribute to these patients' infertility.

Surviving a crash landing: a software review

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Medical computing in the '90s: get ready for a Big Mac attack

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What makes Martin Barkin run?

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Toronto's clinic for HIV-related concerns: coping with a growing caseload

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Spontaneous reversal of flow through jeopardized collateral vessels during non-Q wave myocardial infarction

This case report documents that, when a severely diseased donor artery occludes, sufficient spontaneous reversal of flow through the collaterals can occur to prevent an extensive and possibly fatal transmural infarction.

Maternal serum lipid profile in pregnancies complicated by hypertensive disorders

Plasma lipoprotein, cholesterol and triglycerides were determined in 34 hypertensive pregnant patients and in 17 healthy full term pregnant women. Pregnancy induced hypertension was diagnosed in 21 patients and chronic hypertension in the remaining 13 women. Serum triglyceride levels were significantly elevated in the hypertensive patients. This elevation was not influenced by either the severity or the etiology of the hypertension. The total cholesterol/HDL and the LDL/HDL ratios were significantly elevated in the severely hypertensive patients, and furthermore the LDL/HDL ratio was elevated in patients receiving anti-hypertensive treatment. The lipid profiles found in hypertensive pregnant patients could be associated with enhancement of pathological lipid deposition in predisposed vessels such as the uterine spiral arteries. Furthermore, the hypertriglyceridemia found in the hypertensive patients may be associated with the hypercoagulability reported in pregnancy induced hypertension.

Aortic valvoplasty for traumatic aortic insufficiency: a 2-year follow-up

A 23-year-old man sustained acute rupture of an aortic valve cusp in a motorcycle accident. We repaired the valve using an autologous pericardial patch. A 2-year follow-up two-dimensional echocardiogram and Doppler study show completely normal appearance and function.

Part II: The Difficult Patient Detecting Drug Seekers in Primary Care

Prescription drug diversion is a growing problem facing practitioners, pharmacists, and law enforcement officers in Canada. Prescription drug diversion leads to excess morbidity and mortality. Prescription drug seekers waste the physician's time through unnecessary visits and-should they get caught-through court appearances. The physician's office remains the drug seekers' favourite place to obtain prescription drugs. This article outlines the categories of prescription drugs and the relevant federal laws governing their use. Drug-seeking individuals are described, as are the diseases they feign and the ruses they use to obtain drugs. Finally, ways of circumventing drug seekers are described.

Sheshatshit, Labrador: a town without hope

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Elbow arthroscopy: a new technique

Elbow arthroscopy is a useful diagnostic and therapeutic tool for the orthopedic surgeon. In the standard technique, the patient is positioned supine with the arm suspended overhead and an anterolateral portal is used. We have modified this technique by placing the patient in a prone position and using a proximal medial portal. Use of the prone position improves scope mobility, facilitates joint manipulation, and provides more complete intraarticular visualization. This technique simplifies the treatment of a wide variety of elbow pathology, including loose bodies, osteochondritis dissecans, persistent synovitis, suspected cartilaginous lesions, posterior osteophytes, selected radial head fractures, and chronically undiagnosed painful elbows.

Prenatal diagnosis of Lesch-Nyhan syndrome: experience with three fetuses at risk

Our experience with the prenatal detection of the Lesch-Nyhan syndrome (LNS; hypoxanthine-guanine phosphoribosyltransferase (HGPRT) deficiency) in three fetuses at risk is reported. Enzyme activities were measured in cultured amniocytes in two pregnancies, and in tissues and cultures obtained from chorionic villus sampling (CVS) in a third pregnancy. In all tissues the specific activities of HGPRT and adenine phosphoribosyltransferase (APRT) were determined and APRT/HGPRT ratios were calculated. In addition to the enzyme assays, the rate of purine synthesis de novo was assessed in the two amniocyte cultures, and the rate of [14C]hypoxanthine incorporation into nucleotides and sensitivity to azaguanine were measured in one of the amniocyte cultures. We report the diagnosis of normal fetuses by study of amniocytes in two pregnancies and of LNS using CVS in one pregnancy. In all three cases the diagnosis was confirmed.

Upsurge in malpractice claims, costs may be levelling off

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Programmed oocyte retrieval: clinical and biological effects of oral contraceptives administered before in vitro fertilization

We have prospectively compared two regimens of suppression of the hypothalamic-pituitary-ovarian axis by oral contraceptives (OCs) for 15 or 30 days and two ovarian stimulation protocols. The latent phase, which represents a period of ovarian insensitivity, was prolonged and directly correlated to the duration of suppression. Thirty days' suppression, compared with 15 days', resulted in the cancellation of more cycles and a lower fertilization and pregnancy percentage. No significant increase in either serum progesterone or luteinizing hormone was noted in suppressed cycles. It is concluded that if programming is desired, OCs should be used for the shortest period possible. The variation in the length of the follicular phase indicates that there is a different 'fixed' day for retrieval for each suppression-stimulation protocol and this day should be established prospectively.

In vitro fertilization and primary embryonic cleavage are possible in 17 alpha-hydroxylase deficiency despite extremely low intrafollicular 17 beta-estradiol

Congenital adrenal hyperplasia due to 17 alpha-hydroxylase deficiency in genotypic females is characterized by primary amenorrhea and the absence of sexual maturation due to inadequate biosynthesis of ovarian androgens and estrogens. We induced ovarian follicular development in a woman with this syndrome. Ovum pick-up, in vitro fertilization, and primary embryonic development were achieved despite undetectable plasma estradiol and extremely low ovarian androgen concentrations and minute concentrations of these hormones in the ovarian follicular fluid.

Growth and partial differentiation of presumptive human cardiac myoblasts in culture

A cell culture model for human cardiac myogenesis is introduced. Human fetal myocardial cells were dissociated enzymatically, and cultured in a mitogen-rich medium that promoted the growth of presumptive cardiac myoblasts. Strains of human cardiac myoblasts were generated from different anatomical regions of the fetal heart. The cells could be cultured for at least 30 generations, or frozen and recovered for later use. Differentiation was induced by culturing the cardiac myoblasts in a mitogen-poor medium. Differentiation of cardiac myoblasts was marked primarily by transcriptional activation of the atrial natriuretic factor (ANF) gene. Evidence is presented that posttranscriptional processing of ANF transcripts is affected by the anatomical origin of the cardiac myoblasts and the presence of cocultured neuronal cells. Cardiac myoblasts induced to differentiate in culture synthesized only low levels of sarcomeric myosin and cardiac alpha-actin, suggesting that differentiation of these cells progresses through two phases: an initial, noncontractile phase that is represented by the differentiating cultured cells; and a later contractile phase, in which myofibrillar assembly is accentuated and modulated by secondary signals from the cardiac milieu.

A simplified concept for a bileaflet atrioventricular valve that maintains annular-papillary muscle continuity

We have developed a simplified concept for a bileaflet atrioventricular prosthesis that can be constructed from a simple sheet of glutaraldehyde preserved pericardium. The valve has no rigid ring or stent and no cloth sewing ring. Insertion of the valve reestablishes normal continuity between the annulus and the papillary muscles. We have replaced the mitral valve in nine dogs using this prosthesis. All valves have been competent with excellent valve opening areas as confirmed by echo-Doppler assessment. Studies up to 4 1/2 months have confirmed excellent hemodynamics and there has been no evidence of early tissue failure. Possible advantages of this simple valve design are improved hemodynamics, ease of construction and insertion, and low cost.

Transcervical chorionic villi sampling: a comparison between the silver cannula and the Portex catheter

The Portex catheter and the silver cannula are two of the most widely used biopsy devices for chorionic villus sampling. In a prospective randomized study we used these two devices alternatively in 168 women. Significantly more trophoblastic tissue was obtained with the silver cannula than with the Portex catheter (p less than 0.05) while significantly more failures to obtain villus tissue were recorded with the Portex cannula (8/84 with the silver cannula vs. 19/84 with the Portex cannula; p less than 0.05). In 27 cases where use of the device met with failure to obtain chorionic villi after three attempts the other instrument was then used in the same patient (combined group). Four pregnancies aborted spontaneously after the procedure (2.4%). Significantly more complications occurred in the 'combined' group (4/27 vs. 4/168, p less than 0.05). A higher yield of trophoblastic tissue is possible with the silver cannula than with the Portex catheter.

Pertussis vaccine: why do some parents say no?

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Pertussis vaccine: is the controversy nearly over?

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Home birth: "we did it, all of us"

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Protocols for induction of ovulation. The concept of programmed cycles

Programmed oocyte retrieval which includes suppression of the hypothalamic-pituitary-ovarian axis by oral contraceptives or GnRH analogue and predetermined ("fixed") day for ovum pick-up has been demonstrated to yield a pregnancy rate that is comparable to that achieved by the conventional individualized approach to follicular maturation. We have prospectively compared two regimens of suppression (the pill and GnRH analogue) followed by two ovarian stimulation protocols (clomiphene citrate + human menopausal gonadotropin [CC + hMG] and pure follicle-stimulating hormone + human menopausal gonadotropin [pure FSH + hMG]). Sixteen patients were studied in each group. It was found that the latent phase, which represents a period of ovarian insensitivity, was prolonged and directly correlated to the duration of suppression, and that suppression with the GnRH analogue was associated with a shorter latent phase than that with the pill. Suppression with the pill for 30 days compared with 15 days resulted in a greater cancellation of laparoscopic oocyte retrieval, a lower fertilization rate, and a lower pregnancy rate. The numbers of oocytes recovered, fertilized, and cleaved were similar in both stimulation protocols. The use of the GnRH analogue for 30 days compared with 15 days was associated with a lower pregnancy rate, even though the number of oocytes that were recovered and fertilized were similar. Ovarian stimulation with pure FSH + hMG resulted in a shorter latent phase than did stimulation with CC + hMG, but the results of treatment with both protocols were similar. It is concluded that both the pill and GnRH analogue are acceptable means of manipulating the cycle and the day of oocyte retrieval. However, they should be used for the shortest periods possible because prolonged use is associated with some unwarranted effects. For each suppression-stimulation protocol there seems to be a different fixed day for retrieval that should be established prospectively.

NASA's "space doctor" has the best job on earth

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Clinical results of pericardial xenograft valves: the Ionescu-Shiley and Hancock valves

Between 1979 and 1985, 552 Ionescu-Shiley valves were implanted in 511 patients. The Hancock valve was implanted in 122 patients (129 valves) between 1982 and 1983. Sixty percent of procedures were isolated aortic valve replacements. In the Ionescu series, 59% of these were 19 or 21 mm valves while only 15% of the Hancock valves were of this size. For isolated mitral valve replacement, 76% of Ionescu-Shiley valves were 25 to 27 mm, compared to 36% of the Hancock valves. Patient age, sex, prior operations, concomitant surgery (usually coronary bypass), operative mortality and late deaths were similar for both valves. A mean follow-up of 38 months was obtained for each valve population (99% complete) representing a cumulative 1497 patient-years for the Ionescu-Shiley valve and 375.4 patient-years for the Hancock valve. Actuarial survival for the former was 73 +/- 4% at 72 months, and 65 +/- 14% for Hancock valves at 60 months. The frequency of major events during follow-up (thromboembolism, anticoagulant related hemorrhage, bland perivalvular leak and prosthetic valve endocarditis) were similar, but the frequency of primary tissue valve failure was markedly different for the two valves (1.1% per patient-year for Ionescu-Shiley valves and 5.9% for the Hancock valve). The mean interval to replacement of an Ionescu mitral prosthesis was significantly shorter (23.4 months) than for replacement of an aortic prosthesis (42 months) while the mean interval to replacement of an Ionescu aortic and/or a Hancock aortic or mitral were all similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Five-year follow-up of Hancock pericardial valves: management of premature failure

The durability and function of bovine pericardial valves are dependent upon design, preservation, patient factors (age, sex), and site of valve implantation. In 1983, a shelf recall of all Hancock bovine pericardial valves (HPV) was instituted by the manufacturer. This report represents the results of an organized 5-year follow-up in a hospital Prosthetic Valve Registry of 129 HPV implanted in 122 patients (79 males, 43 females) between May 1982 and April 1985 using echo Doppler and careful clinical evaluation. Mean age was 56 +/- 15 years. There were 81 AVR, 33 MVR, 7 DVR, and 1 TVR. Concomitant coronary bypass was performed in 38 patients (31%). Surgery was on a redo basis in 25 patients (20%), urgent in 14 (11%), and for SBE in 8 patients (7%). There were seven hospital deaths (5.7%). Mean follow-up was 44 months (maximum 66 months) for 114 patients (99% complete), representing 417 patient years. There have been 20 late deaths (18%), of which 7 were directly valve related. Linearized frequency of major events (per pt-yr) was: thromboembolism, 1.6%; anticoagulant related hemorrhage, 0.8% (1 late death); prosthetic valve endocarditis 1.3%; primary tissue failure, 5.8%. Patient symptomatology was a more accurate predictor of bioprosthetic failure requiring reoperation than echo Doppler studies, which were completed in 74 of 97 patients examined during scheduled follow-up visits. Twenty-four of the 96 patients (25%) have required re-replacement at a mean interval of 44 months (27-59 months) from initial implantation. This was due to vertical shear starting at the top of the strut anchoring commissural attachments in every case.(ABSTRACT TRUNCATED AT 250 WORDS)

May I watch? It may become a more common question for MDs

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The influence of abnormal pregnancies on fluorescence polarization of amniotic fluid lipids

The fluorescence polarization of amniotic fluid, a measure of fetal lung maturity, was determined in 518 amniotic fluid samples obtained by amniocentesis. The subjects were divided into seven clinical groups: premature contractions, premature rupture of the membranes, pregnancy-induced hypertension, diabetes, intrauterine growth retardation, vaginal bleeding, and "other" for gestational-age groups of 30 weeks or less, 31-36 weeks, and 37 or more weeks. The proportion of mature values (fluorescence polarization 0.285 or lower) increased progressively from 12.5% at 27-28 weeks to 100% at 39-40 weeks. In the 31-36-week gestation group, the proportion of mature values in subjects with premature rupture of the membranes (84.6%) was significantly higher than in those with premature contractions (60%), severe pregnancy-induced hypertension (50%), mild pregnancy-induced hypertension (55.2%), diabetes class A (50%), insulin-dependent diabetes (60%), and other (63.5%). The mean +/- SD fluorescence polarization value was significantly lower in premature rupture of the membranes (0.256 +/- 0.030) than in premature contractions (0.274 +/- 0.032), mild and severe pregnancy-induced hypertension (0.280 +/- 0.027 and 0.280 +/- 0.035, respectively), and class A and insulin-dependent diabetes (0.285 +/- 0.018 and 0.277 +/- 0.030, respectively). The severity of pregnancy-induced hypertension and diabetes did not appear to influence either the fluorescence polarization value or the proportion of mature results. With the exception of a marked influence of premature rupture of the membranes, abnormal pregnancy conditions did not appear to have a significant effect on fluorescence polarization of amniotic fluid.

Computer simulations may change way medical students taught

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Technique of successful clinical double-lung transplantation

Lung transplantation has become a successful method in the therapy for end-stage pulmonary disease. While single-lung transplantation provides benefit to patients with pulmonary fibrosis, bilateral lung transplants are required for septic or emphysematous lung disease. We describe the technique employed in 6 patients to transplant en bloc both lungs with the recipient heart left in place. The lungs are connected by a left atrial cuff, main pulmonary artery, and trachea. The completed implantation has a tracheal anastomosis securely wrapped in omentum, a left atrial anastomosis posterior to the heart, and a pulmonary artery anastomosis anteriorly. Airway ischemia resulted in the death of 1 patient. This procedure allows complete excision of all diseased pulmonary tissue, retention of the recipient's own heart, and separate excision of the donor heart for use in another recipient, thereby markedly increasing the supply of donor lungs for transplantation.

Health of Toronto's street kids disturbing, study reveals

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Doctors divided: AIDS and the physicians at San Francisco General

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"A plane just crashed": medical teams must be able to improvise

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