Unstable angina--clinical course and medical management including antiplatelet treatment

One hundred patients with unstable angina who were treated medically were classified into 2 groups of non-crescendo and crescendo angina and reviewed regarding their clinical course for 24 months on the average. Thirty-four patients with non-crescendo angina had an occurrence of recurrent angina in 7 patients (21%), myocardial infarction in 2 (6%) and death in none, while 66 patients with crescendo angina had a significantly higher occurrence of recurrent angina in 29 (44%) and myocardial infarction in 14 (21%), p less than 0.05 in both angina and infarction. There were 4 (6%) deaths in patients with crescendo angina in spite of similar clinical backgrounds. Modern medical treatments of unstable angina include nitrates, beta blockers, calcium antagonists as well as antiplatelet and thrombolytic therapy. We conclude that our patients under active medical treatment have more favorable prognosis than once thought and that classification of unstable angina into non-crescendo and crescendo angina according to the early clinical course appears to be useful both for a selection of treatments and for an assessment of prognosis.     

Indication for coronary revascularization for angina pectoris: correlation with prognosis of medically-treated patients

To assess the indication for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG), we studied 93 patients with angina pectoris but without myocardial infarction. All patients had significant stenosis (greater than 50%) in at least one coronary artery, including the left anterior descending artery. Fifty-eight patients received medical treatment (Group I), 12 had PTCA (Group II) and 23 had CABG (Group III). Findings of coronary angiography, treadmill exercise tests and dipyridamole perfusion scintigraphy as well as the frequency of cardiac events during follow-up were assessed in each group. 1. Coronary angiography revealed 1 vessel disease in 38% of the patients in Group I, 58% in Group II, and 13% in Group III; 2 vessel disease in 33%, 25% and 61%; and 3 vessel disease in 29%, 17% and 26%, respectively. 2. Exercise duration with the treadmill test was 4.7 min in Group I, 4.0 min in Group II and 3.7 min in Group III. ST depression (greater than or equal to 1 mm) was induced in 75%, 83% and 95%, respectively. Exercise duration improved from 4.0 to 6.0 min after PTCA and from 3.7 to 4.5 min after CABG. Exercise-induced ST depression also became less frequent; from 83% to 25% after PTCA and from 95% to 32% after CABG. Dipyridamole perfusion scintigraphy showed reversible defects in 86% of the patients in Group I and in all patients in Groups II and III. Reversible defects were observed in 17% of the patients after PTCA and in 21% after CABG. 3. During a mean follow-up period of 26 months, cardiac deaths occurred in one patient (2%) in Group I and 2 (7%) in Group III. Nonfatal cardiac events (myocardial infarction and unstable angina or those necessitating revascularization--late PTCA or CABG) were observed in 12 patients (21%) in Group I, 4 (24%) in Group II and 10 (36%) in Group III. Anginal attacks at least once weekly remained in 12% of the patients in Group I, 19% in Group II and 14% in Group III at the last follow-up. In conclusion, PTCA and CABG appear to be effective methods for improving ischemia and exercise tolerance. However, preventive PTCA and CABG may not be indicated in patients with mild angina, because the prognosis is also excellent in medically-treated patients with angina but without myocardial infarction or left main coronary artery disease.     

Unstable angina: individualized stratification and prognosis.

OBJECTIVE: To analyse the methodology of risk stratification and the prognosis of patients admitted with unstable angina. POPULATION AND METHODS: This retrospective study involved a population of 68 patients (43 males and 25 females with a mean age of 65.8 +/- 9.8 years) consecutively admitted for suspected unstable angina during the year of 1996. Thirty six patients (52.9%) had angina at rest, 13 patients (19.1%) had both exertional and rest angina, 9 patients (13.2%) crescendo angina, 6 patients (8.8%) new onset exertional angina (less than 1 month), and 4 patients (5.8%) post-infarction angina (less than 2 weeks). The risk stratification was individualized. The coronary angiography (35 patients) was only performed when the medical therapy failed in patients with recurrent angina, or with proved ischemia after an exercise test and/or thallium 201 stress scintigraphy. Thirteen patients (19.1%) did not undergo these tests (advanced age and or bad general condition, or refusal). The follow-up of patients with and without ST-T changes was compared, as well as those revascularized versus non-revascularized. It was possible to achieve a mean follow-up of 13.7 +/- 6.2 months (3 to 25 months). RESULTS: The exercise test and/or thallium-201 stress scintigraphy were positive for myocardial ischemia in 28 pts (41.1%) and negative in 7 patients (10.2%). The coronary angiography revealed three-vessel coronary artery disease in 18 patients (26.4%), one vessel disease in 11 patients (16.1%) and two-vessel disease in 5 patients (7.3%). One patient had normal coronary arteries. Medical therapy was the initial approach. Coronary surgery was urgently performed in 3 patients and coronary angioplasty in 5 patients for refractory unstable angina. In the whole group coronary artery surgery was undertaken in 14 patients (20.5%) and coronary angioplasty in 12 patients (17.6%). A mean follow-up of 13.7 +/- 6.2 months was obtained in the 68 patients. During this period 6 patients (8.8%) died due to cardiac causes and 16 patients (23.5%) were readmitted: 8 patients (11.7%) for unstable angina, 5 patients (7.3%) for congestive heart failure and 3 patients (4.4%) for myocardial infarction. Fifty two patients (76.4%) remained free of cardiac events. The patients with transitory ST-T changes had more cardiac events (unstable angina, myocardial infarction, mortality) than the patients without ECG changes (13/30 vs 2/30, p = 0.003). When the revascularized patients were compared to the non revascularized no significant differences were observed regarding myocardial infarction and mortality, however revascularized pts had a less significant incidence of rehospitalization for unstable angina (0/26 vs 8/42 p = 0.02). CONCLUSIONS: An individualized strategy can be effective in pts with unstable angina. In this study 76.4% of patients remained free of cardiac events during the follow-up, 23.6% had severe cardiac events and the cardiac mortality was 8.8%. The patients with transitory ST-T changes had more cardiac events and worse prognosis. No patients significant difference was observed in the revascularized versus non revascularized patients for myocardial infarction and mortality; however, the revascularized patients had less significant incidence of rehospitalization for unstable angina.     

Unstable angina: natural history and determinants of prognosis

One hundred one patients with unstable angina were treated conservatively without the routine use of beta receptor blocking agents, calcium antagonist drugs, anticoagulant agents or nitrates. Only two patients underwent arteriography and coronary arterial bypass surgery during hospitalization and one patient during the 1st year of follow-up study. The 28 day mortality rate was 4 percent and the total 1 year cardiac mortality rate 10 percent. Two patients died from carcinoma. The incidence rate of nonfatal myocardial infarction was 9 percent during the first 28 days and a further 3 percent for the 1st year. These results compare favorably with the immediate and 1 year prognosis reported from other studies using different treatment procedures, including modern intensive drug treatment and coronary arterial bypass surgery. Various factors studied during the acute stage of unstable angina were assessed in an effort to predict the immediate and long-term outcome. Only persistence of pain after admission to the hospital was found a significant indicator of an adverse prognosis. Modern medical treatment of unstable angina with beta receptor blocking agents, calcium antagonist drugs, anticoagulant agents, nitrates and antiarrhythmic agents is critically examined. The paucity of proper randomized controlled studies confirming the value of medication is underlined. There is little evidence to show that aggressive or intensive medical or surgical treatment is superior to a conservative approach to management in the coronary care unit. This approach includes bed rest until the pain has resolved, symptomatic drug treatment only, the minimal use of invasive investigations and careful risk factor intervention.     

Polymorphic ventricular tachycardia in patients with vasospastic angina--clinical and electrocardiographic characteristics and long-term outcome.

There have been few clinical studies exploring the characteristics of spontaneous polymorphic ventricular tachycardia (VT) during a vasospastic angina attack. During a 4-year recruitment period, Holter ECG recordings were monitored for 42+/-24 h during a drug-free period in 60 consecutive patients with vasospastic angina (VSA) and of these, 8 patients had at least one episode of polymorphic VT during monitoring. Ischemic ST segment elevation was immediately preceded the spontaneous polymorphic VT in all 8 patients, 4 of whom had silent coronary vasospasm. Immediately before the onset of polymorphic VT, both R-on-T and long-short sequences were observed in 4 of the 8 patients and ST wave alternans were recorded in 2 patients. VT exhibited a pattern of torsade de pointes in 4 of the 8 patients. Five patients underwent electrophysiologic testing during a drug-free asymptomatic phase, and polymorphic VT was induced in 2 of the 5 patients, with one developing ventricular fibrillation. During a follow-up period of 73+/-17 months, there was a significant difference in the incidence of sudden death between patients with and without VT (2/8 cases [25%] vs 0/52 [0%]; p<0.01). Thus, vasospastic attacks, even if asymptomatic, that immediately precede the development of polymorphic VT may be associated with a repolarization abnormality and an increased risk of sudden death.     

Clinical manifestations and outcome in Staphylococcus aureus endocarditis among injection drug users and nonaddicts: a prospective study of 74 patients

Background  

Endocarditis is a common complication in Staphylococcus aureus bacteremia (SAB). We compared risk factors, clinical manifestations, and outcome in a large, prospective cohort of patients with S. aureus endocarditis in injection drug users (IDUs) and in nonaddicts.     

Scrub typhus: pathophysiology,clinical manifestations and prognosis

Scrub typhus is a zoonosis caused by the pathogen Orientia tsutsugamushi (O. tsutsugamushi). The disease has significant prevalence in eastern and Southeast Asia. Usually presenting as an acute febrile illness, the diagnosis is often missed because of similarities with other tropical febrile infections. Many unusual manifestations are present, and these are described in this review, together with an outline of current knowledge of pathophysiology. Awareness of these unusual clinical manifestations will help the clinician to arrive at an early diagnosis, resulting in early administration of appropriate antibiotics. Prognostic indicators for severe disease have not yet been clearly established.     

Clinical characteristics,treatment, and prognosis of 74 2019 novel coronavirus disease patients in Hefei: A single-center retrospective study

Since December 2019, pneumonia caused by a novel coronavirus (SARS-CoV-2), namely 2019 novel coronavirus disease (COVID-19), has rapidly spread from Wuhan city to other cities across China. The present study was designed to describe the epidemiology, clinical characteristics, treatment, and prognosis of 74 hospitalized patients with COVID-19.Clinical data of 74 COVID-19 patients were collected to analyze the epidemiological, demographic, laboratory, radiological, and treatment data. Thirty-two patients were followed up and tested for the presence of the viral nucleic acid and by pulmonary computed tomography (CT) scan at 7 and 14 days after they were discharged.Among all COVID-19 patients, the median incubation period for patients and the median period from symptom onset to admission was all 6 days; the median length of hospitalization was 13 days. Fever symptoms were presented in 83.78% of the patients, and the second most common symptom was cough (74.32%), followed by fatigue and expectoration (27.03%). Inflammatory indicators, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) of the intensive care unit (ICU) patients were significantly higher than that of the non-ICU patients (P < .05). However, 50.00% of the ICU patients had their the ratio of T helper cells to cytotoxic T cells (CD4/CD8) ratio lower than 1.1, whose proportion is much higher than that in non-ICU patients (P < .01).Compared with patients in Wuhan, COVID-19 patients in Anhui Province seemed to have milder symptoms of infection, suggesting that there may be some regional differences in the transmission of SARS-CoV-2 between different cities.     

慢性阻塞性肺疾病的系统表现及其对预后影响

慢性阻塞性肺疾病（chronic obstructive pulmonary disease．COPD）不仅表现为肺功能异常。而且可引起显著的全身效应。本文综述了近年来国内外有关COPD患者系统表现的研究成果．对认识COPD是一系统性疾病,以及患者的病情评估、治疗及预后有重要意义。     

Electrocardiographic manifestations and in-hospital prognosis of transient acute myocardial ischemia at rest

From January 1970 to June 1985, transient electrocardiographic changes at rest were documented in 652 patients admitted to our coronary care unit. Patients were stratified according to the type of electrocardiographic alteration at rest: 295 had ST-segment elevation (group 1), 106 T-wave changes (group 2) and 251 ST-segment depression (group 3). Patients in group 3, compared with groups 1 and 2, were more likely to have symptoms of coronary artery disease dating back many years (p less than 0.01 and p less than 0.01, respectively), a previous myocardial infarction (p less than 0.05 and difference not significant), a positive exercise test (p less than 0.01 and p less than 0.01), transient ST-T changes occurring in a higher number of electrocardiographic leads (p less than 0.01 and p less than 0.01), multivessel disease (p less than 0.001 and p less than 0.01) and poor ventricular function (p less than 0.01 and p less than 0.05). Despite these differences, the occurrence of acute myocardial infarction and cardiac death during hospitalization was much more frequent in group 1 compared with groups 2 (p less than 0.02) and 3 (p less than 0.05). However, death occurred in those patients who had poor ventricular function and severe atherosclerosis. A greater susceptibility of group 1 patients to severe vasoconstriction documented by the ergonovine test and by the occurrence of spontaneous spasm seems to account for different in-hospital outcome.     

重症监护病房内非粒细胞缺乏患者合并侵袭性肺曲霉菌病38例临床特征及预后分析北大核心CSCD

目的探讨重症监护病房(ICU)内非粒细胞缺乏(非粒缺)患者合并侵袭性肺曲霉菌病(IPA)的临床特征及预后因素。方法回顾性收集2017年2月至2019年2月中日友好医院呼吸与危重症医学科四部(MICU)非粒缺合并IPA患者的临床资料,分析其临床特征和预后因素。结果该研究共纳入38例非粒缺IPA患者。主要临床表现有难治性发热和退热48 h后再发热。影像学方面最常见CT征象的为斑片影和实变,晕征和空气新月征相对少见。气管镜下以支气管黏膜充血、水肿,痰液粘稠多见。痰培养和肺泡灌洗液GM试验的阳性率为分别47.4%、52.9%。此外,有22例患者合并流感病毒感染。预后方面19例好转出院,10例死亡,9例因放弃治疗预后不佳。存活组和死亡组之间在BMI、合并冠心病比率、影像学出现空洞的比率、有创通气支持率、血管活性药物使用率方面存在统计学差异。结论ICU内非粒缺IPA患者的临床表现、影像学均缺乏特异性,当出现反复发热、肺部渗出影、常规抗感染治疗无效时需警惕IPA可能,尤其在合并重症流感时。BMI偏低、合并冠心病、肺部影像出现空洞、需要机械通气和血管活性药物治疗的患者预后不佳。     

Autoimmune manifestations associated with myelodysplastic syndrome predict a poor prognosis

We evaluated the clinical characteristics of autoimmune manifestations (AIMs) associated with myelodysplastic syndrome (MDS) to elucidate whether AIMs impacted MDS outcomes in Japan.This retrospective study including 61 patients who received a new diagnosis of MDS between January 2008 and December 2015 was conducted by the review of electronic medical records for the presence of AIMs within a 1-year period prior to or following the diagnosis of MDS.AIMs were identified in 12 of the 61 (20.0%) patients with MDS. The neutrophil counts and C-reactive protein levels in peripheral blood were significantly elevated in patients with AIMs, and the survival was shorter in those with AIMs compared to those without AIMs. Multivariate analysis demonstrated that the presence of AIMs and higher-risk disease according to the International Prognositic Scoring System (IPSS) were independent risk factors for increased mortality (hazard ratio, 4.76 and 4.79, respectively).This retrospective study revealed that the prognosis was poor in patients with MDS-associated AIMs. The treatment of MDS using the current algorithms is based on prognostic scoring systems such as IPSS. Treatment strategies for patients with MDS-associated AIMs should be reconsidered, even in those with low-risk MDS according to the IPSS.     

Unstable shoes increase energy expenditure of obese patients

BackgroundErgonomic unstable shoes, which are widely available to the general population, could increase daily non-exercise activity thermogenesis as the result of increased muscular involvement. We compared the energy expenditure of obese patients during standing and walking with conventional flat-bottomed shoes versus unstable shoes.MethodsTwenty-nine obese patients were asked to stand quietly and to walk at their preferred walking speed while wearing unstable or conventional shoes. The main outcome measures were metabolic rate of standing and gross and net energy cost of walking, as assessed with indirect calorimetry.ResultsMetabolic rate of standing was higher while wearing unstable shoes compared with conventional shoes (1.11 ± 0.20 W/kg^?1vs 1.06 ± 0.23 W/kg^?1, P = .0098). Gross and net energy cost of walking were higher while wearing unstable shoes compared with conventional shoes (gross: 4.20 ± 0.42 J/kg^?1/m^?1vs 4.01 ± 0.39 J/kg^?1/m^?1, P = .0035; net: 3.37 ± 0.41 J/kg^?1/m^?1vs 3.21 ± 0.37 J/kg^?1/m^?1; P = .032).ConclusionIn obese patients, it is possible to increase energy expenditure of standing and walking by means of ergonomic unstable footwear. Long-term use of unstable shoes may eventually prevent a positive energy balance.     

Musculoskeletal manifestations in hemodialysis patients

One hundred and two consecutive patients receiving maintenance hemodialysis were interviewed and examined to analyze their musculoskeletal problems. Radiographic abnormalities of renal osteodystrophy were found in 23 and there were periarticular calcifications in 5. Only one patient had apatite associated knee arthritis and none had gout or calcium pyrophosphate deposition disease. Twenty patients had arthralgias, 3 polyarthritis, and 4 knee effusions all of which were incompletely explained. Correlations of arthralgias with radiographic findings was poor. Muscle cramps were seen in 24 patients, multiple fractures in one, symmetrical distal neuropathy in 18, and carpal tunnel syndrome in 9.     

Neurological manifestations in dengue patients

To determine the frequency and the natural history of neurological manifestations of dengue infection in Thai children, 1,493 children diagnosed with dengue infection by serology and admitted to the Department of Pediatrics, Chulalongkorn Hospital, Bangkok, Thailand from 1987 to 1998 were reviewed from prospectively recorded medical charts. There were 80 children identified with neurological manifestations, an incidence of 5.4% of all dengue patients. Of these, there were 41 males and 39 females, with ages ranging from 3 months to 14 years. They were categorized into 20 cases of dengue fever, 26 cases of dengue hemorrhagic fever and 34 cases of dengue shock syndrome. All cases experienced the neurological manifestations during the febrile stage of the illness. The patients were classified into an encephalitic group (called "dengue encephalopathy") (42), a seizure group (35) and a miscellaneous group (3). Encephalitic patients presented with alteration of consciousness (83.3%), seizure (45.2%), mental confusion (23.8%), nuchal rigidity (21.4%), spasticity of limbs (9.5%), positive clonus (4.8%), hemiplegia (2.4%) and positive kernig (2.4%), and were older than those in the other groups. Patients in the seizure group presented with seizure (100%) and positive clonus (2.9%). Abnormal laboratory findings included hyponatremia, abnormal liver enzymes and CSF pleocytosis. Dengue IgM and dengue PCR were not demonstrated in 16 CSF specimens. An autopsy finding of a child in the encephalitic group showed histologic evidence of encephalitis, the only case of confirmed dengue encephalitis in this study. One patient with encephalitic symptoms suffered from long-term neurological sequelae. The overall mortality rate was 5%. In conclusion, neurological manifestations including seizure and encephalopathy in children with dengue are not uncommon whereas dengue encephalitis is a rare entity.