Course Of Clinical Management Research Articles

Evaluation of Early Pregnancy Failure with Ultrasound

Abstract Ultrasound has developed into a powerful tool in the management of early pregnancy failure. However, there is no single finding or measurement that should be used in making a final diagnosis of early pregnancy failure. Instead a combination of clinical, hormonal and ultrasound findings should be used when deciding on the clinical management course.

The Utility of Dynamic Flexion-Extension Radiographs in the Initial Evaluation of the Degenerative Lumbar Spine

Retrospective radiographic review. To assess the utility of lateral dynamic flexion-extension radiographs in the initial evaluation of the degenerative lumbar spine. Most surgeons obtain standing anteroposterior (AP) and lateral radiographs in the initial evaluation of patients presenting with lumbar complaints. The potential role of dynamic films in this population has not been established. Of a 390 radiograph series, 342 met inclusion criteria and were reviewed. After assessment of the AP and lateral radiographs, dynamic films were evaluated to determine if additional information was obtained. Only 2 of the 342 radiographic series had new findings seen on dynamic films not appreciated on the AP and lateral films (a L3-L4 anterolisthesis of 3 mm with flexion and a L5-S1 retrolisthesis of 4 mm with extension). Fifteen additional radiographic series were noted to have a change in the amount of anterolisthesis or retrolisthesis on the dynamic films (changes ranged from 2 to 5 mm). In the population studied, dynamic radiographs did not significantly alter the initial course of clinical management beyond standing AP and lateral lumbar images.

Should Liquid-Based Cytology Be Repeated at the Time of Colposcopy?

Five thousand one hundred women age 18–50 years participated in a cervical cancer screening program using liquid-based cytology and human papillomavirus (HPV) DNA testing. Women with abnormal cytology testing, including atypical squamous cells of undetermined significance (ASCUS), or HPV DNA results positive for high-risk HPV types were referred for colposcopic examination. For this study, the liquid-based cytology was repeated at the time of colposcopy to determine the value of repeat screening. The cytology results of the initial screening for 5100 women found 3.3% with high-grade squamous intraepithelial lesions (HSIL), 4.3% with low-grade squamous intraepithelial lesions (LSIL), 9.7% ASCUS, 0.1% atypical glandular cells of unknown significance (AGUS), and 1.3% inadequate smear. Nineteen percent of patients tested positive for high-risk HPV types. In all, 870 women had abnormal cytology at the initial screening; 644 returned for colposcopy. Of 818 women who had negative Pap smear results but were positive for high-risk HPV, 433 returned for colposcopy. In addition, 245 women with normal cytology and negative HPV results agreed to undergo voluntary colposcopy and served as controls. In all, including 18 women with unsatisfactory or missing cytology and positive HPV results, 1340 women underwent colposcopic examination and 1333 had colposcopically directed biopsy. Women with negative or atypical histology, or women whose histologic specimen showed cervical intraepithelial neoplasia (CIN) 1, were referred back to their health clinics. Women who had CIN 2, 3, or adenocarcinoma-in-situ were advised to have the loop electrical excision procedure (LEEP) or cervical conization. Women in whom cancer was found were referred to a gynecologic oncologist for further care. Three cancers were identified in this study population; all were found in the initial screening smear. Among 153 women with HSIL cytology results at colposcopy, biopsy results showed CIN 2 or 3 in 104 (68%) and CIN 1 in 18 (12%). There were 30 women with HSIL cytology results at colposcopy who had negative or atypical histology results. Screening cytology was positive for HSIL in 9 of these patients, but there were 21 women whose initial cytology results and whose biopsy results were negative for high-grade disease. These women were advised to undergo excisional treatment for a high-grade lesion. They are the only patients for whom repeated cytology changed the course of clinical management. The results of the initial Pap smear and the smear taken at colposcopy were compared according to the interval of time between the 2. Among the 21 women with a discrepancy found between initial screening and repeat cytology, 9 were among 686 (1.31%) women who returned for colposcopy within 60 days of the initial screening, 8 were among 509 patients (1.57%) who had colposcopy 61 to 180 days after initial screening, and 4 were among 139 women (2.88%) with more than 180 days between initial screening and colposcopic examination (P for trend = 0.12, not significant).

Lower-Dose Therapy With Traditional Neuroleptics in Chronically Hospitalized Schizophrenic Patients

Several recent studies have shown that relatively low doses and low blood levels of neuroleptics are often as effective as high doses of these drugs both in the treatment of an acute exacerbation of schizophrenia^1-3and in the maintenance treatment of stabilized outpatients with schizophrenia.^4,5Yet, some patients with chronic schizophrenia or related disorders, hospitalized for extended periods, are treated with relatively high doses of neuroleptics for many years. The efficacy of low doses vs standard or high doses of traditional neuroleptics in this group of patients has not been extensively investigated and thus represents an important gap in the low-dose research and treatment strategy. This letter reports an attempt to address this important clinical question. <h3>Patients and Methods.</h3> In the course of clinical management of a service of chronically psychotic female patients, a program of neuroleptic dosage reduction combined with quantitative monitoring of their psychopathologic condition was

Sigmoidoscopy and biopsy in surveillance for cancer in ulcerative colitis.

Surveillance has become an established concept to find dysplasia as a premalignant lesion in ulcerative colitis. Since the advent of colonoscopy and the access of the entire colon to biopsy, utilization of the rigid sigmoidoscope and rectal biopsies has been markedly reduced. We have reviewed 940 rectal biopsies obtained from 360 patients with ulcerative colitis of various extent and duration to determine the yield of dysplasia and assess the value of this procedure. The rectal biopsies had been performed for a variety of reasons in the course of clinical management of ulcerative colitis in addition to surveillance. Dysplasia was found in 10.8% of the patients--higher than has been demonstrated by colonoscopy. In four of the 39 patients with dysplasia a carcinoma coexisted (2) or developed subsequently (2). In no instance did dysplasia serve to warrant the colectomy that disclosed the carcinoma, but earlier discovery of the dysplasia or more intense surveillance once it had been found might have led to earlier discovery of the carcinoma. The yield of dysplasia was greater in those with onset of ulcerative colitis in childhood. In more than half, including 71% of patients with onset in childhood, the dysplasia was found before they had the disease for 9 years. Surveillance, therefore, should begin earlier in young patients with ulcerative colitis. Sigmoidoscopic biopsies do not substitute for colonoscopic biopsies in a surveillance program. Nevertheless, the ease of obtaining rectal biopsies, the relatively large yield of dysplasia, and the need for frequent sigmoidoscopy in the clinical management of ulcerative colitis all warrant a high priority role for rectal biopsies to supplement that of colonoscopic biopsies.

Diagnosis of biliary atresia: Relative accuracy of percutaneous liver biopsy, open liver biopsy, and operative cholangiography

Following necropsy or a minimum of three years of clinical observation an ultimate diagnosis of either biliary atresia or neonatal hepatitis was established in 108 infants with obstructive neonatal jaundice. In this group, the diagnostic accuracy of contemporary percutaneous (needle) liver biopsy and operative (open) liver biopsy was approximately the same. One third of the cases were not correctly identified. Operative cholangiograms usually dictated a correct course of clinical management, but 20 per cent suggested the incorrect diagnosis.