Prospective evaluation of hospitalized patients with nonactive lower intestinal bleeding--timing and role of barium enema and colonoscopy

A prospective evaluation of 176 hospitalized patients with nonactive lower intestinal bleeding demonstrated that a barium enema is not a necessary prerequisite for a sensitive and safe total colonoscopic examination. Colonoscopy was better in detecting colonic polyps and colon cancers than barium enema. It was concluded that colonoscopy without prior barium enema provides a sensitive diagnostic approach to hospitalized patients with nonactive lower intestinal bleeding. This approach does not interfere with the early use of angiography and may shorten hospitalization.     

Comparative functional and physiologic status of active and dropout coronary bypass patients of a rehabilitation program

To assess the benefits of regular participation in a medically supervised cardiac rehabilitation program, 22 patients who had undergone coronary artery bypass (2 groups of 11 each) were studied retrospectively. Group I (mean age 53 years) was currently enrolled in the rehabilitation program. Group II (mean age 56 years) had begun but had discontinued the program. The stated reasons for discontinuation were not medical. There was no difference in entry exercise tests, and presurgical catheterization data in both groups were comparable. Mean peak oxygen consumption (VO₂) by modified Douglas bag technique, heart rate X systolic blood pressure product, and treadmill duration time were recorded in a single testing period. Results revealed that Group I had higher peak VO₂ (30 ml/kg/min) than Group II (24) (p < 0.005) and greater treadmill time (11 minutes) than Group II (8) (p < 0.01). Nine of 11 subjects in Group I were fully employed, versus 4 of 11 in Group II (p < 0.01). One of 11 subjects in Group I had been rehospitalized versus 5 in Group II. None in Group I but 4 of 11 subjects in Group II smoked. Thus, based on the sampling and methodology of this study, it is concluded that coronary artery bypass patients in rehabilitation programs have greater peak VO₂ and treadmill test time, smoke less, are less often rehospitalized, and are more often fully employed than those who are not in such programs.     

Long-term medical management of hypertrophic obstructive cardiomyopathy

Twenty-two patients, aged 15 to 61 years, with hypertrophic obstructive cardiomyopathy documented at catheterization were followed up prospectively for 2 to 8 years (mean 5) while receiving “complete” beta receptor blocking doses of propranolol (average dose 462 mg/day). Hypertension, fluid retention, pulmonary disease and arrhythmias were treated as required. Dyspnea, angina, syncope, presyncope and palpitations were graded from 0 to 3 based on severity, and the scores were added to obtain a total score. This group was compared with 14 nonrandomized control patients, aged 17 to 78 years, who were not receiving propranolol and were evaluated retrospectively for a mean follow-up period of 5 years (range 2 to 13). The average total score for the protocol group was initially 7.9 and is now 1.9. No patient died; the condition of all patients is improved, with an average improvement in dyspnea of 58 percent. Eighteen patients are currently asymptomatic during usual daily activities. In contrast, symptoms increased in severity in 13 of the 14 control patients. Their mean score increased from 2.9 to 5.4, and dyspnea increased by 133 percent. Of the 10 control patients treated only medically, 4 died suddenly.

Improvement in protocol patients was independent of the severity of subvalve obstruction. Potentially life-threatening arrhythmias were found in 11 of the 22 protocol patients, including the 3 patients without obstruction at rest. Rhythm disturbance responded to propranolol alone in four patients, but antiarrhythmic drugs or pacemaker insertion, or both, was required in the remaining seven patients. Thus, “complete” beta blockade supplemented by control of arrhythmia is optimal management for hypertrophic obstructive cardiomyopathy. Most patients do not require surgery.     

Marked cyclic leukocytosis-leukopenia in chronic myelogenous leukemia

A spontaneous oscillation of the white blood cell count was observed in a 58 year old man with chronic myelogenous leukemia (CML). Similar cyclic variations were noted in the platelet and reticulocyte counts with no apparent alterations in marrow cellularity to account for such changes. Since direct correlation was noted between white blood cells, platelets, and reticulocyte counts versus spleen size, it suggests that splenic hemopoiesis may be responsible for these cyclic changes. A possible inverse relationship between colony-stimulating factor (CSF) activity and the white blood cell count was noted, suggesting that CSF may be the humoral agent controlling granulocyte production. A direct correlation between the white blood cell count and serum unsaturated vitamin B12 binding capacity (UBBC) and lysozyme was also noted and further supports the concept that the latter two are measures of the granulocyte pool and metabolism. An inverse relationship between CSF activity and the UBBC suggests that these may be two different entities. Finally a modified form of standard chemotherapy may be effective in inducing remission in cases of CML with marked cyclic leukocytosis-leukopenia.     

Experience with tuberculosis in a public teaching hospital

Over a five-year period, 108 patients with active tuberculosis were admitted to the Talmadge Memorial Hospital in Augusta, Georgia. The age, sex and race distribution, case-fatality ratio, and primary drug resistance data did not differ from the national experience. The high incidence of nonpulmonary infection sites (31 percent) serves to emphasize that all hospital services and medical specialities can expect to encounter active tuberculosis. The only detected cluster of cases was from the state prison. The fact that the disease was not diagnosed or managed effectively in seven of 12 inmates emphasizes its special problem. Delays in diagnosis seemed to be unjustified in 11 patients; seven of these delays resulted from remediable human error. Four delays in diagnosis were due to difficulties that could be corrected by maintaining a greater awareness of tuberculosis and broadening the differential diagnosis to include tuberculosis among patients at high risk.     

Immunologically diagnosed malignancy in Sjögren's pseudolymphoma

Studies of lymphocyte markers in a patient with Sjögren's syndrome who exhibited histologically benign lymphoproliferation in the lung revealed a malignant cell clone. T and B cells were quantitated according to their ability to form spontaneous rosettes with sheep erythrocytes and to fluoresce with fluorescein-conjugated antiserums, respectively. Circulating lymphocytes were 66 per cent T cells (N = 58 ± 2 per cent) and 14 per cent B cells (N = 22 ± 1 per cent), the latter exhibiting normal polyclonal distribution of membrane immunoglobulins. However, lymphocyte suspensions obtained from fresh lymph node and from biopsy specimens from a lymphoid lung nodule revealed 95 per cent and 88 per cent B cells, with 1 per cent and 2 per cent T cells, respectively. Moreover, when cryostat-frozen sections from both tissues were reacted with each of the heavy and light chain-specific antiserums, most cells demonstrated the presence of intracytoplasmic μ kappa immunoglobulin exclusively. Twenty-two months later, a clinically and histologically classic lymphoma developed. Repeat marker studies performed on cells freshly isolated and on frozen sections from the histologically malignant lymph node revealed persistence of the monoclonal marker on most cells.     

Hemodynamic responses to supine exercise in children with left-sided cardiac disease

Exercise, a physiologic stress, has been used in adults to unmask abnormalities of left ventricular hemodynamics not detectable at rest. Similar data in children are not available. An evaluation was made of the feasibility, safety and value of a graded upright and supine ergometer stress test to assess exercise hemodynamics during cardiac catheterization in 21 children with left-sided cardiac disease. The catheterization technique involved the simultaneous recording of intracardiac and great vessel pressures, thermodilution cardiac index and M mode echocardiograms of the left ventricular cavity. The method appears practical and safe. Although hemodynamic responses varied among clinical groups, the lack of control data currently prevents assessment of the value of this technique for long-term management.     

Hemodynamic responses to ergometer exercise in children and young adults with left ventricular pressure or volume overload

This study determines (1) the hemodynamic responses to exercise in groups of young patients with either left ventricular (LV) pressure or volume overload, (2) whether these responses differed from healthy subjects when the variables of sex, age, race and body surface area were controlled (analysis of covariance), and (3) whether any of the exercise variables could predict noninvasively the severity of the gradient in aortic valve stenosis (AS). We tested 137 patients, including 70 with AS, 25 with aortic isthmic coarctation, 20 with aortic regurgitation and 22 with mitral regurgitation, and compared them with a control population of 405 healthy children. The children underwent a continuous, graded, maximal test with 3-minute stages. The variables evaluated were peak heart rate, systolic blood pressure, maximal work load (kgm/min), peak working capacity index (kg-m/min/ kg body weight) and ischemia on electrocardiography.In patients with pressure overload, the maximal exercise values for work load, heart rate and peak working capacity index were significantly different (p < 0.05) from control values. The patients with volume overload had higher blood pressure values than either control subjects or patients with pressure overload. Similarly, the values for heart rate in patients with volume overload were lower than values for control subjects and patients with pressure overload. No exercise variable was predictive of severity of AS. These data confirm some previous investigators' findings with respect to LV volume and pressure overload, but do not support the concept that exercise test results are sensitive and specific for the prediction of severity in AS.     

Rhythm disturbances in hypertrophic cardiomyopathy: Prevalence,relation to symptoms and management

The prevalence of arrhythmias, associated symptoms and the effect of antiarrhythmic therapy were studied in 33 patients with hypertrophic obstructive cardiomyopathy (mean follow-up period 4.7 years). Arrhythmias were found in 29 patients (88 percent) and were potentially life-threatening in 13 (39 percent). Most patients had more than one type of arrhythmia. All patients were symptomatic at Initial evaluation: A history of syncope was noted in 12 patients, of presyncope in 27 and of palpitations in 23. All patients received large doses of propranolol (more than 240 mg/day or more than 3.5 mg/kg per day; average 460 mg/day or 6.7 mg/kg per day) for treatment of hypertrophic obstructive cardiomyopathy. In addition, pacemaker insertion or additional antiarrhythmic therapy was required in 10 patients; these patients underwent repeated Holter monitoring until arrhythmia control was documented, and at least at yearly intervals thereafter.Although some patients had arrhythmias, including short runs of ventricular tachycardia, in the absence of symptoms during ambulatory monitoring and others had symptoms in the absence of rhythm disturbances, the relation between suppression of potentially life-threatening arrhythmias and symptomatic improvement was striking: potentially life-threatening arrhythmias were suppressed in all but one patient, palpitations and episodes of presyncope have decreased in most, syncope has been eliminated in all and there have been no deaths. In addition, atrial fibrillation appears to have been prevented. Symptomatic improvement was independent of the severity of left ventricular outflow tract obstruction.It is concluded that Holter monitoring and stress testing should be a routine part of the evaluation of all patients with hypertrophic cardiomyopathy and that aggressive therapy of potentially life-threatening arrhythmias results in a lessening of palpitations and episodes of presyncope and syncope and appears to prevent sudden death in these patients when combined with large doses of propranolol.     

Exercise-induced cardiac dysfunction in sickle cell anemia. A radionuclide study

Cardiac performance was studied by radionuclide angiography at rest and during exercise in 22 adolescents with sickle cell (SC) anemia and the results were compared with those in 12 control subjects. At rest, cardiac contractility was normal; cardiac output and end-diastolic volume were increased. At maximal exercise, heart rate, cardiac output response, and work capacity were reduced; the reduction was related to the degree of anemia. Left ventricular end-diastolic volume decreased with exercise most markedly in patients with ischemic exercise electrocardiograms. An abnormal ejection fraction response to exercise occurred in 4 patients; electrocardiographic signs of ischemia developed in all 4, and wall motion abnormalities in 2. Those patients who had electrocardiographic signs of ischemia had a significantly lower heart rate, ejection fraction, and cardiac output response to exercise, and a lower hematocrit level than subjects with normal results on exercise electrocardiography. The increase in cardiac output was not sufficient to maintain a normal level of exercise. The decrease in end-diastolic volume suggests that diastolic function was abnormal during exercise. Cardiac dysfunction was manifested by an abnormal ejection fraction response, wall motion abnormalities, and incomplete left ventricular filling during exercise.     

Potentially lethal arrhythmias and their management in hypertrophic cardiomyopathy

The prevalence of potentially lethal arrhythmias (PLA) in groups of patients with hypertrophic cardiomyopathy has been assessed, but the rate at which they develop (their incidence) during long-term follow-up has not been reported. Therefore, conduction system disease (CSD) (sick sinus syndrome and His-ventricular disease), ventricular couplets and ventricular tachycardia (VT) detected by routine electrocardiograms, periodic 24-hour Holter monitoring and periodic exercise stress testing were studied in 50 patients treated with large doses of β-adrenergic blocking drugs who were followed for 2 to 14 years (mean 5.9). Sixteen PLAs detected at the beginning of observation were excluded from actuarial analysis for new PLAs. Twenty-one patients had 24 new PLAs (7 with CSD, 1 patient with sustained supraventricular tachycardia, 6 with ventricular couplets and 10 with VT); only 43% of these PLAs were heralded by new symptoms. In 6 patients, the arrhythmia caused symptoms and was identified by a routine electrocardiogram. The 3 patients with His-ventricular disease presented with syncope and required electrophysiologic confirmation of this diagnosis. In only 1 patient was a PLA (ventricular couplets) detected only by exercise testing. All other ventricular arrhythmias were detected by Holter monitoring. The incidence of CSD in 47 patients free of this condition at entry was 5% at 5 years and 33% at 10 years. The incidence of ventricular couplets or VT in 39 patients free of these at entry was 26% at 5 years and 75% at 10 years, and the incidence of VT only was 18% at 5 years and 40% at 10 years. The incidence of all categories of new PLAs in the 50 patients was 32% at 5 years and 81% at 10 years. Because new PLAs are frequent during long-term follow-up and most cannot be detected adequately without surveillance, periodic Holter monitoring—at least on an annual basis—is recommended.