Giant cell (cranial) arteritis: a clinical review

Giant cell arteritis is a disease of the elderly which is more common than previously recognized. It is important to be aware of this condition because treatment effectively relieves symptoms and prevents serious complications. The disease is suggested when an elderly patient complains of constitutional symptoms, headache, jaw claudication, or the musculoskeletal manifestations of polymyalgia rheumatica. Abnormalities in temporal arteries or other cranial arteries, or evidence of large vessel involvement may be detected by physical examination. A markedly elevated sedimentation rate in association with other clinical features of the disease strongly suggests giant cell arteritis, but a biopsy should be performed to confirm the diagnosis. Corticosteroid therapy should be started promptly in high doses in order to prevent blindness. Prolonged treatment with lower dose corticosteroids is generally necessary for up to 1 to 2 years, and sometimes longer, for continued symptomatic relief. Long-term follow-up of treated patients has demonstrated no detectable effect on survivorship.     

The future of proteomics in the study of alcoholism

This article represents the proceedings of a workshop at the 2003 annual meeting of the Research Society on Alcoholism in Fort Lauderdale, FL. The workshop organizers/chairpersons were Chinnaswamy Kasinathan and Paul Manowitz. The presentations were (1) Introduction to the field of proteomics, by Kent Vrana; (2) Use of proteomics in the identification of urinary biomarkers for alcohol intake, by Chinnaswamy Kasinathan, Paul Thomas, and Paul Manowitz; (3) Proteomics screening illuminates ethanol-mediated induction of HDL proteins in macaques, by Kent Vrana, Randy Gooch, Travis Worst, Stephen Walker, Aaron Xu, Peter Pierre, Heather Green, and Kathleen Grant; and (4) Proteomics applied to the study of the liver, by Laura Beretta.     

Defining Optimal Self-Management in Osteoarthritis: Racial Differences in a Population-Based Sample

The aim of this study was to examine optimal self-management in osteoarthritis and its association with patient-reported outcomes. We recruited a population-based sample of Medicare beneficiaries (n = 551) residing in Allegheny County, PA, USA and elicited an expanded set of self-management behaviors using open-ended inquiry. We defined optimal self-management according to clinical recommendations, including use of hot compresses on affected joints, alteration of activity, and exercise. Only 20% practiced optimal self-management as defined by two or more of these criteria. Optimal and suboptimal self-managers did not differ in sociodemographic features. Both white and African–Americans who practiced optimal self-management reported significantly less pain, but the benefit was greatest in severe disease for whites and for mild-moderate disease among African–Americans. This backdrop of naturally occurring self-management behaviors may be important to recognize in planning programs that seek to bolster self-management skills.     

Verapamil therapy: A new approach to the pharmacologic treatment of hypertrophic cardiomyopathy: III. Effects of long-term administration

To determine the efficacy of long-term therapy with verapamil in patients with hypertrophic cardiomyopathy, 78 patients began treatment with the drug in the hospital. Sixty-two patients (79 percent) were in New York Heart Association functional class III or IV despite treatment with beta receptor blocking drugs. Fifty-four percent of all patients evaluated (42 of 78) and 63 percent of those discharged from the hospital (42 of 68) experienced sustained symptomatic improvement 6 to 30 months (median 14 months) after initiation of verapamil therapy. Of these 42 patients in improved condition, 25 had improvement by at least one New York Heart Association functional class, 14 improved by less than one functional class, two felt better taking verapamil than propranolol, and in one patient verapamil controlled asymptomatic ventricular tachycardia. Of the 53 patients who had the obstructive form of the disorder and were considered operative candidates, 25 (47 percent) experienced sufficient improvement so as to forgo operation. In patients remaining on verapamil therapy, the duration of treadmill exercise performed 5 days after the start of verapamil therapy increased by 3.1 ± 0.6 minutes (53 ± 10 percent, p < 0.001) from the value obtained with no medication before verapamil. A further increase of 2.3 ± 0.6 minutes (25 ± 7 percent, p < 0.0025) over the initial value with verapamil was recorded on the patients' last vistt (median 12 months after the start of therapy). Echocardiographic measurements of wall thicknesses and left atrial dimension demonstrated no significant changes during 1 year of verapamil treatment in 31 patients. Administration of verapamil was associated with adverse hemodynamic effects in 9 patients (12 percent) and adverse electrophysiologic effects In 10 (13 percent): Three patients died (with pulmonary edema) and 6 had to have treatment terminated. These results indicate an important role for long-term verapamil therapy in the treatment of hypertrophic cardiomyopathy, but patients must be carefully selected and followed up closely for the development of important adverse hemodynamic or electrophysiologic effects.     

Femoral artery catheterization complications: A study of 503 consecutive patients

This report describes a prospective randomized trial of 503 patients who underwent a cardiac catheterization or interventional procedure at a single institution. In an effort to study femoral complications postprocedure, we evaluated three methods of femoral artery hemostasis as well as 38 variables that were felt to potentially relate to local complications. Only a marginally significant relationship between the hemostasis method and complication rate was found. The factors that contributed to femoral artery complications were: restarting heparin postsheath removal, number of procedures done during one hospitalization, noncompliance of the patient with bedrest after the procedure, number of arterial punctures to initiate the procedure, and preprocedure treatment with corticosteroids.     

Effects of sidestream smoke exposure and age on pulmonary function and airway reactivity in developing rats

Children exposed to environmental tobacco smoke (ETS) in their homes have in- creased cough, respiratory illness, airway obstruction, and hyperreactivity. Since an animal model is needed to understand the mechanism by which this occurs, our study was designed to determine if immature rats develop airway obstruction and increased airway reactivity when exposed to sidestream smoke (SSS, respirable suspended particulate concentration 1.00±0.03 mg/m³, CO concentration 6.48±0.29 ppm). In the first of 3 studies, rats were exposed to filtered air (FA) or SSS for 6 hr/day, 5 days/week from day 2 to week 8 or week 15 of life (n = 6-8 in each group). SSS exposure did not change lung resistance (RJ, dynamic lung compliance (C_ldyn), lung weighthody weight ratio (LW/BW), pulmonary artery pressure (P_PA), body weight, or airway reactivity to methacholine (all P > 0.2, 2-way ANOVA). Regardless of exposure, lungs from younger rats were relatively heavier and more reactive to methacholine than lungs from older rats (P < 0.05, 2-way ANOVA). In the second study, 15-week-old rats were exposed to FA or SSS for 3 hr or for 4 days (6 hr/day, n = 6 in each group). SSS exposure again had no effect on C_ldym RL, LW/BW, P_pa, or airway reactivity to methacholine (all P > 0.2, ANOVA). In the third study, rats were exposed to FA or SSS from day 2 to week 11 of life (n = 7 in each group). SSS exposure reduced airway (P = 0.004) but not pulmonary artery (P = 0.63) reactivity to serotonin. We conclude that (1) SSS exposure to the immature rats did not mimic the effects of ETS seen in children, (2) younger rats had greater muscarinic airway reactivity than older rats, and (3) serotonin may play a role in ETS-induced lung problems.Pediatr Pulmonol. 1993; 16:281–288. © 1993 Wiley-Liss, Inc.     

Cardiovascular features of homozygous familial hypercholesterolemia: analysis of 16 patients

Familial hypercholesterolemia (FH) is characterized by an autosomal codominant inheritance, an abnormality in low-density lipoprotein (LDL) receptor function, elevated plasma cholesterol levels and premature atherosclerosis. Sixteen patients with homozygous FH were studied to correlate the extent of their atherosclerotic disease with their lipid levels and receptor function. The age range at initial presentation was 3 to 38 years (mean 12), and at the last examination, 6 to 43 years (mean 20). The mean pretreatment total plasma cholesterol concentration for all patients was 729 +/- 58 mg/dl (+/- standard error of the mean), and the mean LDL cholesterol level was 672 +/- 58 mg/dl (normal 60 to 176). High-density lipoprotein cholesterol was 28 +/- 3 mg/dl (normal 30 to 74). In the 7 patients with FH who had symptoms of myocardial ischemia (Group I), the mean pretreatment LDL cholesterol value (817 +/- 62 mg/dl) was higher than that of the 9 asymptomatic patients (Group II) (560 +/- 74 mg/dl). In Group I, 5 of 7 patients had left or right coronary ostial narrowing and 3 had significant left ventricular outflow obstruction. Most coronary arterial narrowing occurred in the right coronary and left anterior descending arteries and the least amount in the left circumflex coronary artery. A femoral bruit was the physical finding that correlated best with the Group I population; brother:sister pairs revealed a milder clinical course for the female. Seven of the 16 patients have survived into their third decade without symptoms. Comparison of these persons with those in whom angina developed reveals a marked heterogeneity in their clinical course, which appears to be associated with receptor negative/defective status.     

Sex differences in early and long-term results of coronary angioplasty in the NHLBI PTCA Registry

To assess whether gender influenced the outcome of percutaneous transluminal coronary angioplasty (PTCA), we analyzed data from the NHLBI PTCA Registry. Early results were compared in 705 women and 2374 men. Women were older (p less than .01) and had more unstable angina (p less than .01), and class 3 or 4 angina (p less than .01). Men had more multivessel disease (p less than .01), prior bypass surgery (p less than .01), and abnormal left ventricular function (p less than .05). Women had a lower angiographic success rate (60.3 vs 66.2%; p less than .01) and had a lower clinical success rate (56.6% vs 62.2%; p less than .01). More women had complications (27.2% vs 19.4%; p less than .01), but overall frequency of major complications (death, myocardial infarction, emergency surgery) was not different (9.8% vs 9.3%). Women had a higher incidence of coronary dissection (p less than .05) and higher in-hospital mortality (1.8% vs 0.7%; p less than .01). PTCA-related mortality was nearly six times higher in women (1.7% vs 0.3%; p less than .001) and mortality with emergency surgery was more than five time higher (17.4% vs 3.2%; p less than .001). Multivariate analysis indicated that female gender was an independent predictor for lower success (p less than .05) and early mortality (p less than .05) and was the only baseline predictor for PTCA-related mortality.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of biplane and single plane left ventricular volumes in atrial septal defect

The close agreement between biplane (BP) and single-plane (SP) angiographic estimates of left ventricular (LV) volumes results from the similarity of the minor axes measured in the right anterior oblique (RAO) and left anterior oblique (LAO) views. Disease states that alter LV geometry may change the length of one minor axis more than the other, producing a discrepancy between BP and SP volumes. To examine this hyposthesis, angiographically derived volumes in 21 patients with atrial septal defects (ASD) in which the LV appears to be compressed and flattened by an enlarged right ventricle, were compared to 100 normal control patients. In the control patients, the median SP estimate of end-diastolic volume (EDV) was 7.6% larger than the BP determination, whereas in patients with ASD, the median SP EDV estimate was 16.7% larger than the BP EDV (P<0.0001). The SP end-systolic volume (ESV) underestimated the BP value by 3.4% in controls but overestimated the BP ESV in patients with ASD by 4.3% (P<0.02). The overestimate of the SP EDV and SP ESV when compared to the BP volumes may be due to changes in either the minor axes or the appearance of the longest major axis in the LAO view. The longest major axis was found in the RAO view in 99% (99/100) of normals and 95% (20/21) of ASD patients (P?NS). The median ratio of RAO to LAO end-diastolic minor axes, however, was 1.07 in the normals and 1.17 for ASD patients. The median ratio of end-systolic minor axes was 0.97 for controls and 1.04 for ASD patients. Compression of the LV in patients with ASD shortens the LAO minor axis, resulting in a significantly greater SP overestimation of LV volume than occurs in normals. The degree of SP volume overestimate was not predicted by the magnitude of the left-to-right shunt or pulmonary pressure. This source of error affects all SP methods for determining left ventricular volume, including radionuclide techniques using static images.     

Principal Dimensions of the Framingham Type A Scale: Differential Relationships to Cardiovascular Reactivity and Anxiety

Abstract

The present investigation sought to identify the principal dimensions of the Framingham Type A scale (FTAS) and then to examine their physiological and psychological correlates. A factor analysis of the FTAS items, which was cross-validated, revealed two factors. Items concerning achievement and competitive-striving loaded primarily on the first factor. Scores on a subscale composed of these items (labeled Competitive Drive) were related to systolic blood pressure reactivity during an interpersonal task but were unrelated to anxiety. FTAS items concerning impatient, time urgent, and domineering propensities loaded primarily on the second factor. Scores on a subscale composed of these items (labeled Speed and Impatience) were not related to cardiovascular reactivity during the task but were related to anxiety. Results are discussed in terms of the psychological heterogeneity of the Type A behavior pattern and possible differences between dimensions of the overall Type A pattern and their association with different manifestations of coronary heart disease.