Results Of Surgical Exploration Research Articles

Objective Analysis of Predictive Value of Ultrasound Quantitative Scoring System for Treatment Method Selection in Cesarean Scar Pregnancy.

This study aimed to explore the feasibility of using the ultrasound quantitative scoring system to guide the selection of surgical methods for a cesarean scar ectopic pregnancy (CSEP). A retrospective analysis was conducted of the medical records of 117 cases of patients with a CSEP. All patients underwent transvaginal ultrasound examination before treatment, and the ultrasound results were compared with the results of surgical exploration. The treatment methods that were delivered for the 2 patient groups with CSEP were analyzed, and agreement between the predicted and actual treatment protocols was tested using the kappa consistency test. Residual myometrial thickness at the scar site was mainly concentrated above 3 mm in the low-risk group, with 70 cases accounting for 76.9%, while in the high-risk group, this was primarily in the range of 1-3 mm with 18 cases accounting for 69.2%. The grading of nourishing blood supply to the gestational sac showed that 96.7% of patients in the low-risk group had Grade I and Grade II blood flow, while 84.6% of the high-risk group had Grade I and Grade II blood flow; Grade II blood flow was predominant in the high-risk group. The majority of patients in both the low- and high-risk groups experienced intraoperative blood loss of ≤50 mL (93.9% vs 80.6%, respectively). The consistency test between the actual and predicted treatment methods yielded a kappa coefficient of 0.644, indicating consistency between the two. For patients with CSEP in the low-risk group (score <4), the ultrasound quantitative scoring system could provide individualized assessment and offer clinically valuable treatment protocols.

An applicability study of rapid artificial intelligence-assisted compressed sensing (ACS) in anal fistula magnetic resonance imaging

ObjectiveTo evaluate the applicability of artificial intelligence-assisted compressed sensing (ACS) to anal fistula magnetic resonance imaging (MRI). Methods51 patients were included in this study and underwent T2-weighted sequence of MRI examinations both with ACS and without ACS technology in a 3.0 T MR scanner. Subjective image quality scores, and objective image quality-related metrics including scanning time, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR), were evaluated and statistically compared between the images collected with and without ACS. ResultsNo significant difference in the subjective image quality of lesion conspicuity was observed between the two groups. However, ACS MRI decreased the acquisition time with regard to control group (74.00 s vs. 156.00 s). Besides, SNR of perianal and muscle in the ACS group was significantly higher than that of the control group (164.07 ± 33.35 vs 130.81 ± 29.10, p < 0.001; 109.87 ± 22.01 vs 87.61 ± 17.95, p < 0.001; respectively). The CNR was significantly higher in the ACS group than in the control group (54.02 ± 23.98 vs 43.20 ± 21.00; p < 0.001). Moreover, the accuracy rate of the ACS groups in evaluating the direction and internal opening of the fistula was 88.89 %, exactly the same as that of the control group. ConclusionWe demonstrated the applicability of using ACS to accelerate MR of anal fistulas with improved SNR and CNR. Meanwhile, the accuracy rates of the ACS group and the control were equivalent in evaluating the direction and internal opening of the fistula, based on the results of surgical exploration.

Preoperative three-dimensional magnetic resonance cholangiopancreatography for choledocholithotomy

ObjectiveTo explore the display effect of preoperative three-dimensional magnetic resonance cholangiopancreatography (3D-MRCP) for choledocholithotomy. MethodsA total of 156 patients with suspected bile duct calculus in our hospital from June 2019 to June 2021 were collected as the research objects. The patients were divided into the preoperative ultrasonography group and the preoperative 3D-MRCP group (78 cases in each group). The detection rate, location judgment accuracy, and surgical effect were compared between these two groups. ResultsThe detection rate of bile duct calculus by 3D-MRCP was 97.4% (76 cases), which was higher than the preoperative ultrasonography (87.1%, 68 cases, P = 0.016). Taking the results of surgical exploration as the gold standard, the location judgment accuracy by 3D-MRCP was 98.7%, which was higher than the preoperative ultrasonography (91.1%, P = 0.036). The operation time, catheter retention time, postoperative ventilation time, and bowel sound recovery time of the 3D-MRCP group were significantly shorter than those of the ultrasonography group (P < 0.05). The postoperative effectiveness of the 3D-MRCP group was 97.4%, which was significantly higher than the ultrasonography group (86.8%, P < 0.05). ConclusionThe preoperative 3D-MRCP has a high detection rate and anatomical site display rate of bile duct calculus, which can improve the operative effect of choledocholithotomy.

Surgical treatment of hourglass-like radial nerve constrictions

IntroductionSpontaneous radial nerve palsy with the surgical revelation of an hourglass-like constriction is a complicated condition. In general, the surgical strategy is decided in accordance with the results of surgical exploration. This study aimed to investigate the efficacies of various choices of surgical methods in the treatment of hourglass-like radial nerve constrictions. Material and methodsTen patients with spontaneous radial nerve palsy undergoing surgical exploration with the revelation of hourglass-like constrictions between November 2010 and December 2018 were reviewed in our hospital. Preoperative physical, electrophysiological and ultrasound examinations were performed for all patients. Varying levels, degrees and numbers of radial nerve constrictions were shown by surgical exposure. Epineurectomy and interfascicular neurolysis were performed in 4 cases with incomplete constrictions; resection and primary suture repair in 2 radial nerves with neurotmesis; resection and autologous nerve grafting in 4 patients with nerve defect>2cm. Both motor and sensory evaluations were performed at a follow-up visit. ResultsTen patients underwent different history before the onset of symptom. Nerve ultrasound demonstrated swelling as well as constrictions of the radial nerve. All patients who were followed up presented with good to excellent recovery of motor function. The effectiveness of suture and autograft repair tended to be better than that of simple neurolysis. ConclusionThe etiology of hourglass-like fascicular constrictive neuropathy of radial nerve involve with torsional factors. Nerve ultrasound is an important and useful measurement in diagnosing the pathology of spontaneous radial nerve palsy and in helping determine surgical approach. The surgical intervention is beneficial for the patients who do not recover in 4 weeks after onset of symptoms and for severe hourglass-like constrictions that are confirmed by preoperative ultrasound imaging. We recommend that nerve grafting be a suitable method in confrontation of nerve defect>2cm.

Preoperative Evaluation of Iatrogenic Spinal Accessory Nerve Palsy: What Is the Place for Electrophysiological Testing?

Electrophysiological testing has been used for the early diagnosis of iatrogenic spinal accessory nerve palsy in clinical practice. However, the presence of low-amplitude compound action potential in 70% to 90% of the patients suffering from iatrogenic nerve transection was reported in several studies. We have encountered the same issue and made minor modifications to the methods of electrophysiological testing. The purpose of this study was to retrospectively evaluate the reliability of our modified electrophysiological testing as preoperative examination in patients receiving surgical revision. In this study, we compared preoperative electrophysiological testing results with intraoperative diagnosis in the 24 patients with iatrogenic spinal accessory nerve palsy who were referred to our hospital from 2009 to 2018. During operation, 20 patients were diagnosed with neurotmesis and the remaining 4 patients were found axonotmesis depending on the results of surgical exploration and intraoperative electrophysiological examination. Six of the 20 patients with neurotmesis demonstrated a low-amplitude compound muscle action potential of the upper trapezius during preoperative electrophysiological testing. Needle electromyography revealed voluntary motor unit potentials in 8 of the 20 patients. Meanwhile, concomitant great auricular nerve or dorsal scapular nerve injuries were preoperatively revealed in 7 of 24 patients. The rate of low-amplitude compound muscle action potentials in these patients suffering from spinal accessory nerve neurotmesis was about 30% with our modified electrophysiological testing. We should be aware of this pitfall before surgical nerve repair. Furthermore, electrophysiological testing is an informative preoperative examination revealing the concomitant nerve injuries.

Clinical research of features of magnetic resonance imaging of high-voltage electrical burns in limbs at early stage

Clinical research of features of magnetic resonance imaging of high-voltage electrical burns in limbs at early stage

Analyses of the clinical characteristics of unilateral conductive hearing loss with intact tympanic membrane

To analyze the clinical characteristics of unilateral conductive hearing loss with intact tympanic membrane, and summarize the key diagnostic points, differential diagnosis and observe the effects of surgical treatment. We reviewed data from 82 patients with unilateral conductive hearing loss with intact tympanic membranes who accepted the exploratory tympanotomy from April 2011 to September 2013. There were 41 males and 41 females, aged from 7 to 66( averaged 26.5±13.7)years, with a history of one month to 50 years. The history, clinical symptoms, audiological evaluation, high resolution temporal bone CT, the results of surgical exploration and hearing reconstruction were analyzed. The exploratory tympanotomy revealed 43 cases of congenital middle ear malformations (52.4%), 22 cases of otosclerosis (26.8%), eight cases of congenital cholesteatoma (9.8%), six cases of trauma induced conductive hearing loss (7.3%), three cases of congenital ossicular malformations with congenital cholesteatoma (3.7%). Progressive hearing loss was common in patients with otosclerosis and congenital cholesteatoma, and patients with congenital middle ear malformations described their hearing loss since childhood. High resolution temporal bone CT of congenital middle ear malformation, trauma induced conductive hearing loss, congenital cholesteatoma diagnosis rate was 40.0%, 50.0%, and 83.3% respectively. The preoperative air-conductive threshold of patients with absence of the oval window were increased to (66.9±1.1)dBHL, the preoperative bone-conductive threshold achieved (28.3±10.4)dBHL at 2 000 Hz. While patients with stapes fixation and that with ossicular chain discontinuity were (27.2±9.7)dBHL and (17.8±8.8)dBHL(P=0.000)respectively. Through the tympanic exploration with endaural incision under the microscope, different hearing reconstruction were applied according to different lesions. After the operation, the hearing level of 52 patients with return visit were improved, the mean air-conductive threshold were decreased from (60.0±11.4)dBHL to (32.2±12.1)dBHL(P=0.000); and the mean ABG were decreased from (43.2±12.0)dB to (16.3±9.4)dB(P=0.000). Congenital middle ear malformations, otosclerosis, congenital cholesteatoma are the most common causes in unilateral conductive hearing loss with an intact tympanic membrane. The diagnosis rate can be improved by analyzing the clinical features. Through exploratory tympanotomy and hearing reconstruction, we can clarify the diagnosis and achieve a satisfying hearing recover.

A Pilot Comparison of 18F-fluorocholine PET/CT, Ultrasonography and 123I/99mTc-sestaMIBI Dual-Phase Dual-Isotope Scintigraphy in the Preoperative Localization of Hyperfunctioning Parathyroid Glands in Primary or Secondary Hyperparathyroidism: Influence of Thyroid Anomalies.

We compared 18F-fluorocholine hybrid positron emission tomography/X-ray computed tomography (FCH-PET/CT) with ultrasonography (US) and scintigraphy in patients with hyperparathyroidism and discordant, or equivocal results of US and 123I/99mTc-sesta-methoxyisobutylisonitrile (sestaMIBI) dual-phase parathyroid scintigraphy. FCH-PET/CT was performed in 17 patients with primary (n = 11) lithium induced (n = 1) or secondary hyperparathyroidism (1 dialyzed, 4 renal-transplanted).The reference standard was based on results of surgical exploration and histopathological examination. The results of imaging modalities were evaluated, on site and by masked reading, on per-patient and per-lesion bases.In a first approach, equivocal images/foci were considered as negative. On a per-patient level, the sensitivity was for US 38%, for scintigraphy 69% by open and 94% by masked reading, and for FCH-PET/CT 88% by open and 94% by masked reading. On a per-lesion level, sensitivity was for US 42%, for scintigraphy 58% by open and 83% by masked reading, and for FCH-PET/CT 88% by open and 96% by masked reading. One ectopic adenoma was missed by the 3 imaging modalities. Considering equivocal images/foci as positive increased the accuracy of the open reading of scintigraphy or of FCH-PET/CT, but not of US. FCH-PET/CT was significantly superior to US in all approaches, whereas it was more sensitive than scintigraphy only for open reading considering equivocal images/foci as negative (P = 0.04). FCH uptake was more intense in adenomas than in hyperplastic parathyroid glands. Thyroid lesions were suspected in 9 patients. They may induce false-positive results as in one case of oncocytic thyroid adenoma, or false-negative results as in one case of intrathyroidal parathyroid adenoma. Thyroid cancer (4 cases) can be visualized with FCH as with 99mTc-sestaMIBI, but the intensity of uptake was moderate, similar to that of parathyroid hyperplasia.This pilot study confirmed that FCH-PET/CT is an adequate imaging tool in patients with primary or secondary hyperparathyroidism, since both adenomas and hyperplastic parathyroid glands can be detected. The sensitivity of FCH-PET/CT was better than that of US and was not inferior to that of dual-phase dual-isotope 123I/99mTc-scintigraphy. Further studies should evaluate whether FCH could replace 99mTc-sestaMIBI as the functional agent for parathyroid imaging, but US would still be useful to identify thyroid lesions.

Diagnostic accuracy of body coil MRI in describing the characteristics of perianal fistulas

The purpose of this study was to determine the accuracy of synergic body coil MRI using SPIR technique without contrast, in the determination of fistula characteristics in patients with clinically positive signs. This was a case-series prospective study including 29 consecutive patients with clinically suspected fistulas-in-ano. The standard synergic body coil was used and all patients had T2-weighted SPIR sequences. One radiologist, without prior knowledge of the clinical examination, analysed images and noted the presence of the fistula, its classification and the presence and number of any collections or extensions. The surgeon noted the MRI findings and looked for lesions suggested on MRI. The results of the MRI and surgical assessments were then compared. Results of surgical exploration while the surgeon was aware of MRI results were considered as the gold standard of surgical anatomy. Twenty-three (79.31%) of 29 fistula tracks were seen on MRI which correctly determined the type of all fistulas. In the six cases where the fistula was not seen on MRI, five were low trans-sphincteric and one was rectovaginal. MRI identified 8 of 10 collections. The synergic body coil MRI with SPIR sequencing without endoanal coils had a high accuracy in the diagnosis of high fistulas collections, complex fistulas and extensions.

L'imagerie préopératoire des hyperparathyroïdies des insuffisants rénaux a-t-elle un intérêt en pratique clinique ?

Aim of the study. – To evaluate the efficiency of preoperative parathyroid ultrasonography and scintigraphy in the management of renal hyperparathyroidism. Patients and methods. – The charts of the last consecutive 200 patients who underwent surgery for renal hyperparathyroidism from 1998 to 2003 were retrospectively reviewed to collect data concerning parathyroid gland function, results of preoperative ultrasonography and scintigraphy, as well as modalities and results of surgical exploration. Results. – Ultrasonography and scintigraphy sensibilities were 36.4% and 49.3%, respectively. Efficiency of both examinations was improved when they were combined (sensibility of 64.7%) and in those patients managed for recurrent hyperparathyroidism. Were more often detected by preoperative examinations glands with high weight and/or greatest diameter, orthotopic and inferior glands as well as glands exhibiting nodular hyperplasia content upon pathological examination. Conclusion. – Parathyroid ultrasonography and scintigraphy are of poor interest in the management of renal hyperparathyroidism. In a preoperative setting, they should be performed only in patients with recurrent disease.

Sonovaginography is a new technique for assessing rectovaginal endometriosis

Objective To evaluate the efficacy of a new technique, the sonovaginography, for the assessment of rectovaginal endometriosis. Design Prospective study. Setting University hospital. Patient(s) Forty-six women were scheduled for laparotomic or laparoscopic surgery because of rectovaginal endometriosis suspected on the basis of patient history and/or clinical examination. Intervention(s) Before surgery, all the women underwent transvaginal ultrasonography and then sonovaginography. The latter is based on transvaginal ultrasonography combined with the introduction of saline solution to the vagina that creates an acoustic window between the transvaginal probe and the surrounding structures of the vagina. Ultrasound findings were compared with the results of surgical exploration and histological examination. Main outcome measure(s) We assessed the accuracy of transvaginal ultrasonography and of sonovaginography for the detection and the location and extension assessment of rectovaginal endometriotic lesions, as well as compared patient compliance between the procedures. Result(s) Sonovaginography diagnosed rectovaginal endometriosis more accurately than did transvaginal ultrasonography, with a sensitivity and specificity of 90.6% and 85.7%, respectively, whereas the transvaginal ultrasonography has shown a sensitivity and specificity of 43.7% and 50%, respectively. Patient discomfort did not differ significantly between the procedures. Conclusion(s) Sonovaginography is a reliable and simple method for the assessment of rectovaginal endometriosis and provides information on location, extension, and infiltration of the lesions, which are important factors in selecting the kind of surgery.

The diagonal ventricular dimension: a method for predicting shunt malfunction on the basis of changes in ventricular size.

Serial computed tomographic and magnetic resonance imaging studies are critical in the evaluation of patients who present with symptoms and signs of recurrent hydrocephalus or possible ventricular shunt malfunction. Subtle changes in ventricular volume or complex variations in ventricular anatomy often make subjective assessment of changes in ventricular size difficult, and no previously described method relates these changes to intracranial pressure or shunt system function. The purpose of this study was to develop an objective, reproducible, simple linear method of detecting changes in ventricular size that provides an accurate reflection of shunt function on the basis of serial imaging studies. We developed a simple, linear estimate of ventricular volume--the diagonal ventricular dimension--to objectively assess changes in ventricular size on serial computed tomographic scans and magnetic resonance imaging scans. Serial imaging studies for 14 patients ages 1.6 to 71 years who underwent evaluation for shunt malfunction were used in this study. The sensitivity and specificity of this method in predicting shunt malfunction was compared with other well-established linear estimates of ventricular size as well as with a radiologist's interpretation of the same studies. The "gold standard" for measuring the status of ventricular shunt system function in this study was the measurement of intracranial pressure via shunt tap or surgical exploration results. The sensitivity (100%) and specificity (100%) of the diagonal ventricular dimension in detecting changes in ventricular size consistent with shunt malfunction was superior to that of any other linear estimate and to a radiologist's interpretation of the same films. The diagonal ventricular dimension provides an objective, simple linear method of assessing changes in ventricular size that correlates well with shunt system function in the context of a collaborative examination.

External oblique aponeurosis nerve entrapment as a cause of groin pain in the athlete.

Groin pain in sportsmen is a common management problem. The results of surgical exploration in 25 male athletes presenting with groin pain are described. All patients had had failed non-operative management. All groins were explored via an inguinal incision and the patients were reviewed for the presence of pain, function and their own subjective opinion. Nineteen injuries were unilateral and six bilateral. One patient had an occult inguinal hernia and another had a patent processus vaginalis. In the others, defects were found in the external oblique aponeurosis through which neurovascular bundles containing terminal branches of the iliohypogastric nerve passed. These tears were repaired after division of the bundles. The mean time to referral was 29.3 weeks (range 4-79 weeks). After operation no pain or only mild pain was experienced in 28 groins. All had improved function. Twenty of 23 patients described the operation as good or excellent. The mean time to resumption of sporting activities after operation was 11.6 (range 4-20) weeks. Athletes' groin pain may be due to nerve entrapment in the external oblique aponeurosis. An awareness of this injury may reduce delays in operating leading to an earlier return to sport.

Evaluation of canine lumbosacral stenosis using intravenous contrast-enhanced computed tomography.

The objective of this study was to evaluate intravenous contrast-enhanced computed tomography as a technique for predicting the within-level location(s) of compressive soft tissues in the canine lumbosacral spine. Pre-operative intravenous contrast-enhanced computed tomography of the L5-S3 vertebral levels was performed in 12 consecutive large breed dogs with lumbosacral stenosis. The images were evaluated for enhancement of soft tissues by two radiologists who were unaware of the surgical findings. For each within-level location (dorsal canal, ventral canal, right lateral recess, left lateral recess) enhancement was classified as present, absent or equivocal. The results were compared with the results of surgical exploration and histopathology of excised tissues. The positive predictive values of intravenous contrast-enhanced computed tomography for compressive soft tissues involving the dorsal canal, ventral canal and lateral recesses were 83%, 100%, and 81% respectively. Negative predictive values for compressive soft tissues involving these locations were 29%, 50%, and 40% respectively.

Surgical repair of orbital fractures: how soon after trauma?

PURPOSE: To determine the results of surgical exploration soon after orbital trauma in comparison with surgery half a year or longer after trauma. METHODS: A retrospective study was done on 41 patients with motility disorders after trauma. Full ophthalmologic and orthoptic investigation was done in all patients. CT-scans and/or X-ray photographs were also made. The 41 patients were divided into two groups. One group of 13 patients did not need surgical repair. One group of 28 patients needed an operation. RESULTS: In 13 patients there was an orbital fracture but no surgical repair was needed. In 28 patients surgical repair was done. In 8 patients the operation was performed half a year or longer after trauma, 15 patients underwent surgery within two weeks after trauma, and 5 patients within two months. CONCLUSION: The best final results were obtained when the operation was done soon after trauma; however, the results in the patients who were operated late were fairly good too.

Accuracy of DSA in the Evaluation of Patency of Infrapopliteal Vessels

To evaluate the accuracy of intraarterial digital subtraction angiography (DSA) in the demonstration of patent infrapopliteal vessels. One-hundred sixty-five arteriograms were obtained in 153 consecutive patients prospectively enrolled to evaluate lower extremity ischemia. In 86 cases a follow-up angiogram of the infrapopliteal vessels was obtained during surgery or after endovascular intervention (n = 57). Twenty-nine arteriograms were followed by surgical exploration of the infrapopliteal vessels. Standard angiographic technique was performed with intraarterial DSA of the most symptomatic foot. Visualization of distal vessels was compared with intraoperative or postintervention imaging or with the results of surgical exploration. Of the 57 procedures after which either intraoperative or post-endovascular intervention angiography was performed, DSA results were equivalent in 47 (82%) and worse in five (9%). When individual vessels were evaluated, the sensitivity of DSA in the identification of patent named vessels was 95%, and the specificity was 92%. Among 29 cases with a surgical standard of reference, 28 patients underwent bypass to a vessel correctly identified as patent at DSA; one patient was incorrectly identified as having no patent named vessels. Intraarterial DSA is accurate and reliable in the assessment of patency in infrapopliteal vessels before surgery or endovascular intervention in patients with infrainguinal atherosclerotic disease.

Orbital Fistula, Infection, and Cysts-Reply

In Reply. —We were very much impressed by the interesting problem Gordon raised as the cause-and-effect relationship between the coexisting infection and fistulas or cysts, whereby he maintained that fistula or cyst formation should precede the course of infection rather than vice versa. Generally speaking, it might be just as hard to deny the fistula or cyst formation predating the infectious process as to disprove the reversed condition, eg, fistula or cyst formation presents itself as sequence of infection or trauma. As far as our series of 20 cases of orbital fistulas are concerned, we are rather inclined to define the cause-and-effect relationship between the fistula and infection in favor of the latter than of the former. Our conclusion was amply substantiated and confirmed by case history, data of physical examination, roentgenogram findings, and results of surgical exploration as well as of treatments. In no case of our series had

Role of the phonocardiogram in evaluation of the severity of mitral stenosis and detection of associated valvular lesions.

The phonocardiogram was correlated with hemodynamic measurements and with the results of surgical exploration in 141 patients with pure or dominant mitral stenosis. The study revealed the following results: 1. A diastolic murmur at the apex was absent in only two of 141 patients. [see figure in the PDf file] 2. The opening snap (OS) was absent in 29% of all patients and in 10% of patients with pure mitral stenosis and noncalcified mitral valve. The most important single factor contributing to the absence of an OS was calcification of the mitral valve. Other factors included young age and associated aortic stenosis or mitral insufficiency. 3. There was no significant correlation between the (Q-1)-(2-OS) interval (PCG index) and the diastolic pressure gradient across mitral valve at rest. The correlation between the PCG index and the calculated mitral valve area (MVA), and the diastolic pressure gradient across the mitral valve during exercise was significant ( P &lt;0.05). 4. The PCG index correctly predicted whether the MVA was smaller or greater than 1.2 cm 2 in 85% of patients with pure mitral stenosis but in only 57% of patients with associated lesions. The MVA was less than 1.2 cm 2 in 36 of 39 patients with pure mitral stenosis in whom the PCG index ranged from +2 to +6. Of 42 operated patients with pure mitral stenosis, the PCG estimate was correct in 36. The PCG index did not underestimate MVA in any of the operated patients. 5. In a group of patients with the same left atrial (LA) pressure, the 2-OS interval was longer in patients with low cardiac output. The relation between the 2-OS interval and the cardiac output could explain in part the lack of correlation between LA pressure and 2-OS interval and the smaller number of correct estimates of MVA made by the 2-OS interval as compared to the Q-1 interval and the PCG index. 6. There was no significant correlation between the amplitude of the first sound at the apex and the severity of mitral stenosis. Several patients with associated mitral insufficiency had a first sound of high amplitude. 7. There was no significant correlation between the amplitude of the sound of pulmonary valve closure (P 2 ) and the pulmonary artery pressure. P 2 amplitude was significantly greater in slender patients. 8. An apical systolic murmur was recorded in 48% of patients with pure mitral stenosis. The longer the murmur, the greater was the likelihood of associated mitral insufficiency. A pansystolic murmur at the apex usually indicated an associated mitral or tricuspid insufficiency.