Biomedical subjects
Publications and source records attributed to C A Sivaram.
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Myocardial infarction (MI) complicating pregnancy in a renal transplant recipient is described. Management challenges of MI in pregnancy and the possible predisposing roles of renal transplantation and erythropoietin (EPO) use are discussed.
BACKGROUND: Guidelines for the use of telemetry in hospitalized patients have been proposed by the American College of Cardiology (ACC). However, there have been only a few studies which have investigated the usefulness of these guidelines in clinical practice. HYPOTHESIS: This study assessed the role of telemetry in the decision making process outside the critical care units. METHODS: The observational study, lasting 4 weeks, was conducted in the telemetry unit of a tertiary care teaching hospital and included 61 male patients (age range 40-61 years). They had been directly admitted to the telemetry unit or transferred from a critical care unit and were followed for as long as telemetry was active. Indication for telemetry and the contribution of telemetry to management decisions were assessed by a physician not involved in the care of the patient. RESULTS: Cumulative number of telemetry days was 379 with a mean of 6.2 days per patient. Total number of telemetry events was 297. According to the ACC classification, 14 patients (22.9%) had class I indication, 21 patients (34.4%) had class II indication, and 26 patients (42.6%) had class III indication. Telemetry events were seen in 18.2% of class I patients, in 39.7% of class II patients, and in 42.1% of class III patients. Only 12 telemetry events (4%) resulted in patient management, with none belonging to class III. CONCLUSION: Telemetry findings in patients outside the critical care units are not usually responsible for major therapeutic changes. The value of telemetry in such patients may be overrated.
An elderly man with pulmonary vein varix and atrial fibrillation is described. The diagnosis of pulmonary varix, a localized dilatation of pulmonary vein, was made by transesophageal echocardiography. The patient had chronic atrial fibrillation, and transesophageal echocardiography demonstrated thrombus in the pulmonary varix. In patients with atrial fibrillation, pulmonary varix may be an unusual site for thrombus formation.
Calciphylaxis is a rare manifestation of abnormal calcium metabolism seen in some patients with renal disease. We describe the transesophageal echocardiographic (TEE) findings in a patient with calciphylaxis. These findings included calcification of ascending aorta and aortic valve. TEE was normal before the development of calciphylaxis.
A cardiac transplant recipient with multiple coronary artery fistulae draining into the right ventricle is described. These fistulae presumably resulted from repeated endomyocardial biopsies. The diagnosis of coronary artery fistulae was made at the annual coronary arteriography. The magnitude of the shunt remained small over eight years of follow-up.
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The angiographic, echocardiographic, and electrocardiographic correlates of ST-segment elevation during high-dose dobutamine-atropine stress were prospectively looked at in a group of high-risk patients. Unlike exercise-induced ST elevation, ST-segment elevation with dobutamine-atropine stress, while indicating transmural ischemia, did not increase rate of arrhythmias and hence by itself may not be an indication to terminate the test.
PURPOSE: To introduce case management to a general medicine ward team of a teaching hospital to improve patient care and ensure comprehensive longitudinal care. METHOD: The Department of Veterans Affairs Medical Center is one of four hospitals used by University of Oklahoma School of Medicine residents. There are five medicine teams, each comprising a second- or third-year resident, one or two interns, two medical students, and a faculty physician. The case-management program was initiated in November 1994. No attempt was made to limit the residents assigned to the case-managed team (i.e., many residents who worked with the case-managed team subsequently rotated through the other teams). Patients were assigned to the teams by rotation, and no attempt was made to adjust for the severity of illness among admissions. The teams were separated as follows: pre-case-management teams (all five teams prior to the case-management program), non-case-management teams (the four teams without case managers after the program's initiation), and the case-management team. The study periods were January-July 1994 (pre-case management) and January-July 1995 (after case management). RESULTS: The numbers of patients treated by the three groups were 1,305, 1,139, and 289, respectively. The median length of stay for pre-case-management patients was 5 days (interquartile range, 3-9 days); for non-case-management patients, 5 days (range, 3-8 days); and for case-management patients, 5 days (range, 3-7 days). The cumulative distribution of lengths of stay for case-management patients was significantly different from those of the other study groups by the Kolmogorov-Smirnov test (p = .02). More case-management patients were discharged by day 7. Rates of readmission were not significantly different between the teams. CONCLUSION: In this study a case-management program was effectively implemented in a teaching hospital, resulting in reduced lengths of stay for patients. As academic health centers become more concerned with efficiency and cost, case management should be seriously considered as a way to deal with such issues.
The authors report the diagnosis and successful management of a 57-year-old man with right ventricular outflow tract obstruction from a large pseudoaneurysm of the left anterior descending coronary artery 5 years after he had undergone redo coronary artery bypass grafting.
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BACKGROUND: Idiopathic left ventricular tachycardia (ILVT) characterized by QRS complexes with right bundle-branch block (RBBB) morphology and left axis deviation is a distinct clinical syndrome that also demonstrates a characteristic response to verapamil and inducibility from the atrium in patients without structural heart disease. A false tendon has been described in the left ventricle in a patient with ILVT in whom surgical resection of the false tendon resulted in cure. We hypothesized that the false tendon is responsible for the genesis of similar ventricular tachycardia (VT) in others. METHODS AND RESULTS: We performed transthoracic (TTE) and/or transesophageal (TEE) two-dimensional echocardiograms in 15 patients undergoing catheter ablation for ILVT. There were 12 men and 3 women (mean age, 31 +/- 12 years, with average symptom duration of 11 +/- 9 years). The mean VT cycle length was 360 +/- 70 ms, and all had RBBB morphology with left axis deviation. Cardiac chamber sizes, left ventricular wall thickness, and wall motion were normal in all ILVT patients. TTE and/or TEE demonstrated a false tendon extending from the posteroinferior left ventricular free wall to the left ventricular septum in all ILVT patients. The false tendons were thick (> or = 2 mm maximal thickness) in 5 patients and thin (< 2 mm maximal thickness) in 10 patients. We compared ILVT patients with a control group of 671 consecutive patients referred for echocardiography for other reasons. The mean age for the control group was 42 years. A false tendon was seen in the left ventricle in 34 of 671 (5%). In the control group patients with a false tendon, 2 patients had a history of VT (left bundle-branch block morphology) and 1 had ventricular fibrillation. The false tendons in the control patients were also oriented transversely across the ventricular cavity but were somewhat thinner (< 2 mm maximal thickness in 32 of 34 patients). Catheter ablation with the use of radiofrequency and/or direct current applied to the posteroapical septum resulted in cure in 14 of 15 patients. CONCLUSIONS: A false tendon extending from the posteroinferior left ventricle to the septum is a consistent finding in patients with ILVT and probably is responsible for this unique arrhythmia. The mechanism by which the false tendon precipitates tachycardia is speculative, but possibilities include conduction through the false tendon or by producing stretch in the Purkinje fiber network on the interventricular septum.
BACKGROUND: Most hospitals that monitor adverse drug reactions (ADRs) through reporting by nurses, pharmacists, medical record technicians, and quality improvement staff experience low rates of reporting. In teaching hospitals, inadequate orientation about the hospital activities, frequent changes in rotations between hospitals, and time commitments to educational pursuits may all undermine house staff's ability to perform ADR monitoring. The authors describe their experience since 1989 at the Department of Veterans Affairs Medical Center in Amarillo, Texas, in the use of verbal ADR reporting by physicians (mostly house staff) during the morning report in the medical service. ADR MONITORING PROGRAM: The morning report begins with a discussion of adverse outcomes of medications, usually from the previous 24 hours. The staff physicians use the opportunity to address the nature of the ADRs and the clinical circumstances leading up to them. Some ADR episodes require further peer review by a physician before being forwarded to the Pharmacy and Therapeutics Committee. EFFECT OF THE PROGRAM: Since the start of the ADR monitoring program in 1989, the number of self-reported ADRs in the medical service has increased over historical controls, even though no special training was given to house staff to detect ADRs. The surgical and psychiatric services, which did not hold morning reports, did not experience the same increase in ADR reports. CONCLUSIONS: The ADR monitoring program is notable for the simplicity of the reporting mechanism, the integration of the reporting into the regular work flow activities, the concurrent nature of the reporting, the educational opportunities, and the potential benefit for quality improvement of patient care.
BACKGROUND: Transfer of cardiac patients between hospitals is a complex process with many implications for quality of care. In the case of heart disease, specialized procedures such as coronary angioplasty, coronary bypass surgery, and valve replacement or repair require the performance of cardiac catheterization and coronary arteriography in a catheterization laboratory, as well as the availability of cardiac surgical services. The Department of Veterans Affairs Medical Center (DVAMC) at Muskogee, Oklahoma, transfers most cardiac patients requiring specialized diagnostic procedures and advanced cardiac care to DVAMC at Oklahoma City, Oklahoma. Concerns about the inefficiency of the transfer process led to the launch of a quality improvement project in late 1992. CHANGES IN THE TRANSFER PROCESS: Greater emphasis was placed on medical aspects compared to administrative aspects of transfer, and ready access to the physicians at DVAMC at Oklahoma City was provided. RESULTS: The time from request for transfer to the actual transfer decreased. Before the quality improvement project, only 33% of transfers of cardiac patients were completed within 24 hours-versus 78% in 1993 and 1994, 89% in 1995, and 84% in the first half of 1996. In addition, DVAMC-Muskogee physician satisfaction regarding services at DVAMC-Oklahoma City improved. CONCLUSION: Ongoing discussion between the cardiology team at the accepting hospital and physicians at the referring hospital expanded the continuum of care to both hospitals. Priority of transfers could be upgraded at any time without unduly jeopardizing patient safety or increasing resource utilization at the receiving center.
OBJECTIVE: To assess the value of the routine electrocardiogram (EKG) in the management of older (> 65 years) patients with cardiac disease during return visits to the ambulatory clinic. DESIGN: Retrospective chart analysis. SUBJECTS: Seventy-one patients older than 65 years of age, with cardiac diagnoses, presenting for follow-up visits. METHODS: Chart notes from 254 encounters with 71 patients in a cardiology clinic were analyzed. Excluded were new patients as well as patients followed in special arrhythmia clinics for pacemakers or significant arrhythmias. All patients underwent an EKG during each clinic visit, irrespective of their clinical status, according to the clinic's protocol. The frequency and nature of therapeutic decisions made in the clinic, the contribution of the EKG to the decision-making process, the appropriateness of the EKG, and the physician response to the EKG were assessed. MAIN RESULTS: Therapeutic decisions, the most common of which (28%) was medication changes, were made in 78 (31%) patients. The routine EKG was considered inappropriate in 60%. Unexpected diagnostic information not obtained from history or examination was not present in any encounter. EKG findings were not addressed by physicians in 22%. CONCLUSIONS: Most older patients seen in the cardiology clinic for return visits with stable symptoms do not benefit from EKGs. Unexpected diagnostic information from the EKG leading to major therapeutic decisions is rare in older people with stable symptoms.
Localized pericardial effusion leading to cardiac tamponade is seen occasionally in patients after cardiac surgery. This condition may be difficult to diagnose clinically because of unusual presenting symptoms and absence of conventional signs of cardiac tamponade. A case of localized pericardial effusion with presenting symptoms of fever and increasing fatigue is described in this study. The definitive diagnosis was made using transesophageal echocardiography. Surgical drainage of localized effusion resulted in prompt hemodynamic and symptomatic improvement.
Thrombosis of upper extremity veins and superior vena cava (SVC) can occur in patients with indwelling central venous catheters. Contrary to earlier reports, pulmonary embolism (PE) can result from these thrombi, especially when they are attached to catheters (sleeve thrombi) in contrast to venous wall (mural thrombi). Removal of catheters may be required when sepsis occurs or to reduce risk of sepsis when lines have been left in for several days. We describe two patients with thrombi in SVC related to central venous catheters in whom transesophageal echocardiography (TEE) was performed during catheter removal to monitor for thrombus dislodgement. TEE may have a role in showing thrombus dislodgement and embolization during removal of venous catheters complicated by SVC thrombi. Direct visualization of thrombus dislodgement may aid in early diagnosis of PE because signs and symptoms of PE are often missed or mistaken for underlying cardiopulmonary disease. TEE may also play a role in implementing appropriate treatment in patients with PE who show right ventricular strain.
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