Biomedical subjects
Publications and source records attributed to J A Spittell.
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Chest pain in a young person is often caused by chest wall tenderness, associated with mitral valve prolapse, or attributed to psychologic factors. Ischemic cardiac pain may be overlooked because of its rare occurrence in this age group. A 35-year-old woman complained of substernal chest pressure precipitated by exertion and relieved by rest. The symptom had been noted for 15 years. Worsening of the symptom during dancing prompted her to seek medical advice. She had no other illnesses, was taking no medications, was a nonsmoker, and had no family history of coronary disease. Physical examination disclosed a grade 1 (on the basis of 1 to 6) systolic ejection murmur, an ejection click, and a grade 2 diastolic murmur. An exercise test produced symptoms at 4 minutes. Coronary arteriography showed the absence of a left coronary ostium and filling of the entire coronary system from the right ostial injection through collateral vessels from the right coronary artery. Surgical repair was recommended. Operative intervention showed a dysplastic bicuspid aortic valve with a membrane that covered the left coronary ostium. Excision of the membrane reestablished antegrade blood flow to the left coronary system. A follow-up exercise test revealed normal findings. Because chest pain in a young person is rarely ischemic in origin, benign or noncardiac causes are usually considered; however, if the history suggests ischemic pain, the possible presence of unusual cardiovascular abnormalities should not be disregarded.
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The most common cause of intermittent claudication is atherosclerotic occlusive arterial disease. Differentiation of the common musculoskeletal and neurologic conditions that may mimic intermittent claudication is often possible with a careful history, but when insufficient detail is provided or multiple conditions exist, the findings on physical examination and noninvasive studies are useful. While physical examination provides a rough estimate of the degree of ischemia, assessment of functional impairment produced by occlusive arterial disease is best made with noninvasive studies before and after standard exercise. Arteriography is reserved for the patient for whom restoration of pulsatile flow is planned.
Approximately 100 cases of pregnancy in women with cardiac valve prostheses have been reported in the world's medical literature. In most instances, the need for continuous anticoagulation therapy constituted a major concern in the obstetric management of these high-risk pregnancies, particularly since coumarin has been implicated as causing an increased frequency of fetal wastage or birth defects (or both). Of all women who received cardiac valve prostheses at the Mayo Clinic between 1965 and 1975, 23 conceived 40 times after the procedure. Fetal wastage was more than doubled in women receiving coumarin therapy at conception and during the first trimester, as compared with that in women not receiving coumarin therapy. Fetal wastage exceeded 80% in women with multiple-valve prostheses who received coumarin therapy throughout early pregnancy. There were no serious maternal sequelae in any of the women. One infant of a mother receiving anticoagulation therapy had mild nasal hypoplasia, but there were no other congenital anomalies in which coumarin had been previously implicated.
Among 52 cases of prosthetic valve endocarditis, adequate anticoagulant therapy was administered in 38 and discontinued or given in subtherapeutic dosage in 14. Our data suggest that anticoagulant therapy does not appreciably increase morbidity or mortality in patients with prosthetic valve endocarditis. On the contrary, in our patients the incidence of major clinical CNS (central nervous system) complications was increased and the mortality was higher if anticoagulant therapy was discontinued. CNS complications occurred in 10 of the 14 patients without adequate anticoagulant therapy and in three of the 38 with adequate anticoagulant therapy. Mortality was 57% among those treated without adequate anticoagulation and 47% among those with adequate anticoagulation. At autopsy, CNS complications were thought to be the primary cause of five of the eight deaths in cases without adequate anticoagulation.
The popliteal vessels rank second only to the external iliac system as the most frequent site of acquired arteriovenous communication. Direct trauma to the popliteal space is by far the most common cause, and surgical intervention is usually required to manage the defect. We present a recent illustrative case following meniscectomy. To our knowledge, the occurrence of an arteriovenous fistula complicating knee surgery has not been reported previously. This case outlines the potential value of B-mode ultrasound in diagnosis and the use of intraoperative angiography in assessing the adequacy of primary vascular reconstruction. Earlier experience of this vascular abnormality--six additional cases since 1941--is reviewed.
Forty-eight patients undergoing elective repair of an abdominal aortic aneurysm were randomly selected for correlation of diagnosis of aneurysm and aneurysm size as determined by direct surgical measurements, ultrasound examination, and lumbar spine X-ray. The preoperative diagnosis was confirmed by lumbar spine plain films in 72% of patients and by B-mode ultrasound in all of patients. Aneurysm size could be measured by lumbar spine X-ray in 55% of patients and with gray-scale B-mode ultrasound in all of patients. The average difference between surgically measured and roentogenographically determined aneurysm size was 1.5 cm in the transverse diameter and 0.87 cm in the anteroposterior diameter of the aneurysm. The average difference between surgically measured aneurysm size and ultrasound-determined external wall diameter of the aneurysm was 0.42 cm in the transverse diameter and 0.29 cm in the anteroposterior diameter. From these data we conclude that gray-scale B-mode ultrasound of the aorta is a more sensitive and accurate method of assessing abdominal aortic aneurysms than is the use of lumbar spine X-ray.
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In late 1972, a survey of Mayo Graduate School alumni was undertaken to determine if changes were needed to make the internal medicine residency program more relevant to such medical practice in the 1970s. Responses were obtained from 783 of the 1,109 former residents in internal medicine to whom questionnaries were sent. Althought nearly half of the responders indicated a subspecialty component to their practice,73% indicated they spend more than half of their time in the delivery of parimary car; and additional 15% reported that primary care occupied from 20% to 50% of their professional time. There was agreement that more general internists are needed and that better geographic distribution of physicians would improve health care delivery.
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