A study of the course of rheumatic heart disease

In this study of the course of 160 cases of rheumatic heart disease, it was disclosed that at the time of examination at the Mayo Clinic 81 per cent of the patients were less than fifty years of age. The disease occurred most commonly in the fifth decade, forty-seven cases (29 per cent). Only seventeen patients (19 per cent) were more than fifty. The sex incidence was equal, and no striking differences were found in a comparison of the data divided on the basis of sex. The first attack occurred before the age of thirty in 136 cases (85 per cent) and before the age of twenty in 103 cases (64 per cent). The primary infection occurred in only five cases (3 per cent) after the fortieth year. The average age at the time of death was thirty-two years.The cases were divided into three groups for comparative study according to the clinical diagnosis of valvular involvement. In Group I with mitral involvement there were 124 cases, in Group II with aortic involvement twenty-one cases, and in Group III with both mitral and aortic involvement, fifteen cases. In Group I, fifty-one patients were males and seventy-three females; the first rheumatic infection occurred before the thirtieth year in 106 cases (85 per cent), and in only three cases (3 per cent) was the first attack after the fortieth year. The average age at death was thirty years. In Group II there were nineteen males and two females; rheumatic infection occurred before the thirtieth year in seventeen cases (81 per cent); the average age at death was forty-three years. In Group III there were ten males and five females; in thirteen (86 per cent) the initial rheumatic infection occurred before the thirtieth year; the average age at death was thirty-two years.Recurrent rheumatic infections were most prevalent in the first decade of life in which they occurred in sixteen cases (55 per cent). The greatest number of attacks in any one case was eight. There was no instance of recurrent infection after the thirtieth year. There was only one instance of recurrent infection in Group II. No constant relationship is revealed in this study between the number of attacks of rheumatic fever and the age at which death occurred. There is little difference between the incidence of recurrent infection in the two sexes. In sixty-two cases (39 per cent) there was congestive failure at the time of examination. Auricular fibrillation occurred in sixty cases (38 per cent). Death from gradual heart failure occurred in 147 cases, while sudden death occurred in eight cases. Five patients died from subacute bacterial endocarditis.     

Prognosis of acute porphyria: occurrence of acute attacks, precipitating factors, and associated diseases.

We evaluated the prognosis of acute porphyria among 206 adult Finnish patients with acute intermittent porphyria (AIP) or variegate porphyria (VP). The series represents all known patients with these porphyrias in Finland. Of the 47 patients who had a total of 117 acute attacks during the period 1967-1989, 6 died during an attack and 21 attacks were associated with paresis; the frequency of severe attacks was significantly smaller than before 1967 (p = 0.00002). Most pareses and deaths occurred because of a delay in diagnosis and inappropriate treatment of porphyria. For those patients who were symptom-free at the time of diagnosis (1365 follow-up years), the risk of the first subsequent attack was significantly smaller than for those who had had an acute attack before the diagnosis of porphyria (1047 follow-up years, p = 0.005). In addition, milder symptoms of porphyria were more common among those who had had previous attacks than among those who had not (p less than 0.00001). In AIP the risk of attacks correlated with the excretion of porphobilinogen in the urine during remission among adults (p = 0.03); a low rate of excretion predicted freedom from acute attacks. A regular use of many precipitating drugs was never associated with symptoms of porphyria. Two percent of the surgical operations and 4% of the pregnancies were associated with acute attacks. Nearly one-third of the women had symptoms of porphyria associated with the menstrual cycle, but these seldom proceeded to an acute attack. Forty-six percent of the women had used sex-hormone preparations regularly; 2 of them (4.5%) experienced associated acute attacks. Patients with AIP or VP showed increased incidences of hepatocellular carcinoma, and probably also chronic renal failure and hypertension.     

The status anginosus induced by paroxysmal auricular fibrillation and paroxysmal tachycardia

We have reported here four unusual but important cases to illustrate the fact that a status anginosus may occur without coronary thrombosis.A great increase in heart rate due to paroxysmal auricular fibrillation or paroxysmal tachycardia (with accompanying drop in systolic blood pressure or pulse pressure) was evidently responsible for the induction of the angina pectoris that was at other times a characteristic result of effort in all of these four cases. Two of the patients were men, aged sixty-two and sixty-six years, and two were women, aged sixty-eight and seventy-five years. One of the men (the first) and one of the women (the second) died suddenly eighteen months and fifteen months, respectively, after the first attack of angina pectoris induced by the abnormal heart rhythm. The other two patients were alive one year after their first attacks of this nature.     

Documented symptomatic hypoglycaemia in children and adolescents using multiple daily insulin injection therapy

Symptomatic episodes of documented hypoglycaemia were characterized with the aid of a 3-month diary in a single-centre, unselected group of 161 children and adolescents with Type 1 diabetes mellitus, treated mainly (81 %) with multiple-dose insulin therapy. Patients and families were asked to write in the diary all the symptomatic episodes in which blood glucose concentration proved to be ⩽3 mmol l⁻¹ before treatment. Of the patients, 83 (52 %) had a total of 287 hypoglycaemic episodes (0.6 attack per month per patient). The majority of the attacks, 221 (77 %), were mild (patients ⩾6 years able to treat themselves). Only two attacks were severe, resulting in coma and/or convulsion. The most common dominant symptoms were weakness (29 %), tremor (20 %), hunger (14 %), and drowsiness (12 %). Of all the dominant symptoms, 39 % were classified as autonomic, 20 % neuroglycopenic, and 41 % non-specific. In children under 6 years, autonomic symptoms were less common than in adolescents 15 years or over (34 % vs 57 %, p = 0.01). In conclusion, the incidence of documented symptomatic hypoglycaemia was low. The symptoms were more often neuroglycopenic or non-specific than autonomic, especially in young children. © 1998 John Wiley & Sons, Ltd.     

马来丝虫病急性淋巴管、淋巴结炎反复发作的研究

[目的 ]阐明丝虫与细菌感染对马来丝虫病急性淋巴管、淋巴结炎反复发作的作用。 [方法 ]1逐月访视病人 ,观察急性炎症发作季节消长。2在急性期患者的炎症部位取样作细菌培养 ;在急性发作过后不同时期作血清抗链球菌溶血素‘O’效价测定。3采取有效控制丝虫病传播或乙胺嗪治疗急性炎症史患者 ,观察急性发作的变化。 [结果 ]1发现急性发作高峰与蚊媒传播季节高峰相一致。2在急性发作患者中 ,97例作细菌培养 ,90例为阴性 ;2 5 5例作抗‘O’效价测定 ,初次发作和单纯炎症患者 94.1% (143/ 15 2 )未见效价增高。3在丝虫病传播得到有效控制后 ,急性炎症年发作率 ,初发和单纯炎症史患者迅速显著下降。4仅对急性炎症史者采取抗丝虫成虫治疗未能证实其减少炎症发作的效果。 [结论 ]在马来丝虫病流行区 ,急性淋巴管、淋巴结炎反复发作的主要原因是 ,丝虫病传播存在 ,患者受到重复感染 ,由感染期幼虫侵入人体后激发所致。     

Nonspecific proctocolitis in northeastern Scotland: a community study

An extensive retrospective survey of patients with onset of symptoms of nonspecific protocolitis arising in the decade 1967-1976 was carried out in northeastern Scotland, including the Grampian region, Orkney, and Shetland. Five hundred and thirty-seven cases were identified, and a 97% follow-up was achieved. One hundred and twenty nonhospitalized cases were included. The average annual incidence was 11.3 per 10(5) population, the highest recorded in Europe to date. Moreover, a striking rise in the incidence was noted. A bimodal age distribution and urban predominance was found. The frequency of both nonspecific proctocolitis and Crohn's disease in first-degree relatives was high. The disease was found to be less severe and extensive at onset than suggested by other surveys, 70% having only distal involvement and 68% having a mild first attack. The overall mortality and surgical resection rates in the first attack were both 3%. Severe first attacks carried a striking 23% mortality. The observed long-term mortality differed little from the expected, except in patients with extensive disease or severe first attacks, or both. The risk of relapse correlated with decreasing age at onset but not with the initial extent or severity of disease. The surgical resection rate after 5 yr was 8%. Twelve percent of patients extended their disease by 5 yr. Using the patient-year concept, 68% of patient years were remission years. The youngest age group had the highest percentage of attack years. The percentage of attack years for all patients correlated more closely with extent of disease in each patient year rather than extent of disease at diagnosis.     

Factors influenceing long-term prognosis in male patients surviving a first coronary attack.

Three hundred and sixty-four men who survived a first episode of acute coronary insufficiency or myocardial infarction for 28 days were admitted to a coronary heart disease secondary programme between 1 January 1961 and 31 December 1971. Of these, 252 have been followed for at least 4 years. The 4-year mortality was 13.5 per cent (34 patients). The average mortality was 3.4 per cent but an excess of deaths occurred during the first year of follow-up. Of 11 characteristics measured during the acute attack, only severity of the attack was significantly associated with poor 4-year survival. Cigarette consumption after infarction was significantly less among those surviving the 4-year period when compared with decedents. Follow-up systolic and diastolic blood pressure levels were significantly lower among decedents. No significant differences were noted in serum cholesterol levels and in mean weight, The presence of post-infarction angina did not affect the prognosis.     

A follow-up study of 48 patients with Reiter's syndrome

A follow-up study of 48 patients with Reiter's syndrome was carried out in an attempt to clarify the clinical course of the disease. The mean age at the onset of Reiter's syndrome was 27.1 years (range 15 to 52 years) and when seen at follow-up 32.5 years (range 19 to 58 years). The average time from the onset of the first attack of peripheral arthritis to the time of follow-up was six and a half years (range 0.5 to 27 years). Only three patients had diarrhea prior to the onset of Reiter's syndrome. At follow-up 22 per cent of the patients were asymptomatic, 24 per cent had recurrent minor symptoms, 24 per cent had recurrent moderate symptoms, and 30 per cent had recurrent major symptoms. However, even in the last group, all patients were in functional classes 1 or 2 between the flares of disease. No patients in the series were in functional class 3 or 4, and 30 per cent were in class 1.     

Mortality risk assessment and the role of thrombolysis in pulmonary embolism

Acute venous thromboembolism remains a frequent disease, with an incidence ranging between 23 and 69 cases per 100,000 population per year. Of these patients, approximately one-third present with clinical symptoms of acute pulmonary embolism (PE) and two-thirds with deep venous thrombosis (DVT). Recent registries and cohort studies suggest that approximately 10% of all patients with acute PE die during the first 1 to 3 months after diagnosis. Overall, 1% of all patients admitted to hospitals die of acute PE, and 10% of all hospital deaths are PE-related. These facts emphasize the need to better implement our knowledge on the pathophysiology of the disease, recognize the determinants of death or major adverse events in the early phase of acute PE, and most importantly, identify those patients who necessitate prompt medical, surgical, or interventional treatment to restore the patency of the pulmonary vasculature.     

Diverticular disease of the colon in the younger age group

Summary and Conclusions Twenty-three patients, 45 years of age or less, were studied with special reference to recurrent attacks of diverticulitis. The virulent course of diverticulitis in these patients was revealed by an operative rate of 61 per cent. Surgery was necessary for complications in 46.6 per cent subsequent to the first and only attack of diverticulitis. Nine patients had primary resections of the colon with no mortality. Staged procedures prolonged the period of recovery; an average of 50.5 days’ hospitalization was required in these cases. Diverticulitis in young persons is a progressive disease. This possibility can be eliminated by prophylactic resection, as shown in the case of the 45-year-old man with an eight-year history of severe morbidity. Read at the meeting of the American Proctologic Society, Pittsburgh, Pennsylvania, June 21 to 24, 1961.     

Idiopathic nonhistaminergic angioedema.

PURPOSE: We sought to describe the characteristics of a group of patients with idiopathic nonhistaminergic angioedema and their response to prophylactic treatment with tranexamic acid. METHODS: We identified 25 patients (15 men and 10 women; age at diagnosis 16 to 77 years) who had idiopathic nonurticarial angioedema that was not prevented by histamine-1 (H1) blockers. Known causes of angioedema were excluded by clinical history, physical examination, and diagnostic tests. RESULTS: The median age at the onset of symptoms was 35 years (range 8 to 66). The frequency of attacks was > 12 per year for 16 patients, six to 11 per year for 6 patients, and one to five per year for 3 patients. All patients had cutaneous attacks, 13 (52%) reported swellings of the pharynx or larynx, and 5 (20%) had symptoms consistent with bowel angioedema. Because of the similarities between these patients and patients who are deficient in C1 inhibitor, the 15 patients with severe and frequent attacks were started on prophylactic treatment with the antifibrinolytic agent tranexamic acid, 1 g three times a day orally for 3 months, tapered according to its effectiveness. The symptoms of 11 patients decreased to less than one attack per year, and the remaining 4 patients had partial remissions (less than 4 attacks per year). Fourteen patients are still being treated with tranexamic acid. CONCLUSION: Patients with idiopathic nonhistaminergic angioedema appear to have similar clinical features and response to treatment with tranexamic acid as those who are deficient in C1 inhibitor. This suggests that those two forms of angioedema might have, at least in part, a similar pathogenesis.     

The arthritic complaint in primary care: prevalence, related disability, and costs.

Surveys conducted in five areas of Southern Ontario obtained clinical and service utilization data from 5,478 adults over 25 years of age. The two week period prevalence rates of arthritic and rheumatic (AR) complaints were 1.72 per cent and 2.14 per cent among two groups of users of primary care. In free-living general populations, the rates ranged from 6.23 per cent to 8.84 per cent. It was shown that only 25 per cent of complainants with AR symptoms sought health services. Of all adults seen by family physicians in one year, 28 per cent presented at least once with an AR complaint. While 20 per cent of all respondents reported some physical impairment, 43 per cent of those with AR complaints had impairment. The excess impairment was two per cent. Complaints with AR symptoms used health services at costs 78 per cent higher than the average expenditures in the same communities. The essential role of the primary care practitioner in the identification and control of AR disorders is strongly supported.     

Surgical treatment of pulmonary tuberculosis in Greenland

Surgical treatment of pulmonary tuberculosis in Greenland. Follow-up of 1, 143 patients operated on for pulmonary tuberculosis at Queen Ingrid's Hospital, Godthåb, during the years 1954–1966. In particular the main group consisting of 785 resected patients is reviewed. Overall operative mortality was 1.0 per cent. At follow-up 2–12 years after surgery 104 (9 per cent) had died, and 1, 039 were in good health. Of the survivors 78 per cent were fully and 12 per cent partially fit for work while 1 per cent were unfit. Of the 1, 039 survivors 95 per cent were back at work within one year after surgery; 90 per cent had resumed their old occupation while only 6 per cent had changed occupation because of the tuberculosis. There was a close relationship between impaired work capacity and the nature and extent of the operation. By Greenland standards housing conditions of the survivors were satisfactory for 80, unsatisfactory for 5 and poor for 14 per cent.     

Posterior basal cardiac infarction affecting a young man,followed a year later by anterior apical infarction

According to our search of the literature, 318 cases of coronary thrombosis among patients less than 41 years of age have been reported. If we were able to validate two additional cases reported in foreign journals, the total would be brought to 320.Our patient, whose case is here reported, suffered two attacks of coronary thrombosis. The first attack occurred at the age of 39 years, and resulted in infarction of the posterior basal portion of the left ventricle; the second occurred at the age of 40 years, and caused infarction of the anterior apical portion. The electrocardiograms depiet the accuracy with which this diagnostic aid may reflect the presence and the location of myocardial infarction.     

Tuberculous meningitis: a 10-year analysis at the "Dr. Federico Gómez" Children's Hospital of Mexico

Of all the forms of tuberculous infection in children, the most frequent is the pulmonary, but the tuberculous meningitis is the most severe and mortal, it occurs mainly in children under five years old, and the highest mortality is in children under two. The results of a retrospective study carried out at the Children Hospital of Mexico "Dr. Federico Gómez" about all the patients hospitalized with tuberculous meningitis diagnose during the January 1975 to December 1985 period were presented. One hundred and eighteen cases were studied: the majority (80%) corresponded to children under four years old, a percentage of 79 presented some degree of malnutrition, and 86 per cent showed clinical data of neurological affection. The confirmation of the diagnose was made in the majority of cases through laboratory and cabinet studies. Forty per cent showed no alteration in the chest X-rays, and the isolation of the bacillus was in a very low percentage (15%). All the patients were treated with the antituberculous drugs mentioned, with a better development in the ones associated with steroids. The hospital stay was over 30 days in 15 per cent of the cases. The mortality of the series reviewed was 44.5 per cent.     

Sudden and unexpected natural death; coronary artery sclerosis

Among 2,030 cases of sudden and unexpected natural death autopsied over a six and one-half-year period in the Borough of Manhattan, New York City, in 45 per cent, death was attributed to diseases of the heart and aorta. Of these, two-thirds (30.4 per cent of the 2,030 cases) were caused by coronary arteriosclerosis. This percentage of coronary artery disease in the cardiac and aortic group corresponds almost exactly with that reported from Berlin, Germany, over an eight-year period.Sudden death from coronary artery sclerosis occurred most frequently in white men (90 per cent). The three decades between 44 and 74 years contributed one and one-half times their percentage share of the population, but sudden death from this disease began to appear in the third decade. Death took place under no specific circumstances.In almost three-fourths (75.5 per cent) of the hearts, coronary artery sclerosis, and not fresh thrombosis, was responsible for vascular occlusion. In the remaining cases, a not always fresh thrombosis was encountered and an underlying sclerosis, usually of severe grade, was always present. It is incorrect to attribute death to coronary thrombosis without indicating the underlying primary sclerotic disease of the arteries.Cardiac hypertrophy was found in 117 (66 per cent) of the 163 subjects whose deaths were analyzed during a two-year period. It was more prominent in the presence of myocardial fibrosis.     

Incidence and clinical picture of sarcoidosis in a circumscribed geographical area

The incidence and clinical picture of sarcoidosis were studied on the basis of an unselected series of 354 sarcoidosis patients (168 men, 186 women) in a defined geographical area during the years 1970-81. All the patients were examined in hospital. The mean annual incidence of sarcoidosis was 15 cases per 100 000 population 15 years or older. Sixty-four per cent of the cases began or were diagnosed in the first half of the year (P less than 0.001). The disease was diagnosed in 67% of the male cases and 38% of the females before the age of 35. Sarcoidosis was found by mass chest radiographic survey or by chance in 99 men (59%) and 103 women (55%), but 85 men (51%) and 129 women (69%) had symptoms of the disease. Two hundred and eighteen patients (62%) had bilateral hilar adenopathy upon diagnosis of the disease, 120 (34%) parenchymal changes and three fibrotic radiographic changes. Lung function test results tended to decrease with the radiographic stage and were indicative more of obstruction than restriction.     

The first ten years of rheumatic infection in childhood

The results of a follow-up study of 547 children who were observed for a ten-year period following the onset of rheumatic infection have been presented.At termination of the initial attack, 59.2 per cent showed evidence of the presence of rheumatic heart disease.Of 219 individuals with no clinical evidence of heart disease at termination of their first attack, 76.7 per cent still showed no evidence of heart disease ten years after onset. Only 5 per cent of this group with potential heart disease at onset had died of rheumatic infection or bacterial endocarditis.Of 318 individuals with rheumatic heart disease at onset, thirty (9.4 per cent) showed disappearance of signs of cardiac inyoly ment. Of this group with rheumatic heart disease at onset, 42.1 per cent had died of rheumatic infection or bacterial endocarditis.The most significant prognostic factor, in so far as the initial illness is concerned, is related to the presence or absence of obvious signs of cardiac damage. Chorea at onset is relatively benign because it is less likely to be associated with carditis than is polyarthritis or other types or rheumatic infection.Ten years after onset, 60.3 per cent of these rheumatic individuals were leading a normal existence with little or no limitation of activity. The majority of individuals presenting no functional incapacity, however, were those who showed no clinical evidence of heart disease at the termination of the initial attack. Twenty-four and four-tenths per cent of the total group had died of rheumatic infection, the predominant number of deaths occurring among those in whom a diagnosis of rheumatic heart disease had been made following recovery from the first attack. Death had occurred in only 5 per cent of the group in whom an original diagnosis of potential heart disease had been made, in comparison with a death rate of 42 per cent among those diagnosed as having rheumatic heart disease at onset.     

Five-year survival of 728 patients after myocardial infarction. A community study.

This study deals with the five-year survival of 728 myocardial infarction patients who survived the first 28 days after the onset of symptoms. The series was collected by the Helsinki Coronary Register and includes all cases of acute myocardial infarction in the population who were under 66 years of age during the period 1 July 1970 to 30 June 1971. Of the 219 patients who subsequently died, 81.8 per cent died from ischaemic heart disease. The mortality was highest during the first year after the acute phase but did not decrease after the second year. The mortality was higher in patients with a transmural infarction (five-year mortality 34.0%) compared with those with a nontransmural infarction (19.7%). The mortality also was higher for recurrent acute myocardial infractions than for first attacks. The five-year mortality for women was less (20.5%, age-adjusted) than for men (31.6%). This is mainly because of the higher incidence of nontransmural infarcts in women. Acute ischaemic heart disease is more common, more often fatal, and has a poorer long-term prognosis in men than in women in Helsinki. The acute mortality from acute ischaemic heart disease is high in Helsinki when compared with other WHO registers and, in addition, the long-term prognosis seems to be relatively poor in Helsinki.     

Prognosis in gastric cancer; a study of 5-year survivors

Of 377 patients with gastric carcinoma 115 or 30.8 per cent survived resection; twenty-eight, 7.4 per cent of the 377, survived five years.Fifty per cent of the five year survivors had had symptoms of over a year's duration as compared with 31 per cent of the initial group. The symptoms were essentially identical in type. Palpable tumor masses were present in 40 per cent of the original group as compared with 26.6 per cent of the survivor group.Nine of the survivors had type I (Borrmann) carcinoma, seventeen had type II and four had type III; there were no five-year survivors in the Borrmann type IV group.Metastases were present in 23 per cent of the five-year survivors, five with lymph node involvement, one with mesenteric involvement and a seventh with spread to the transverse colon.Eighty per cent of the five-year survivors were restored to useful life.