Biomedical subjects
Publications and source records attributed to L L Basta.
Legionella pericarditis is a rare and serious manifestation of Legionnaire's disease. A case is presented in which the diagnosis was established by direct fluorescent antibody staining on a pericardial tissue specimen. Video-assisted thoracoscopy was used safely and effectively in diagnosis and management in this case.
BACKGROUND: Despite the fact that coronary artery disease is the leading cause of death among women, previous studies have suggested that physicians are less likely to pursue an aggressive approach to coronary artery disease in women than in men. To define this issue further, we compared the care previously received by men and women who were enrolled in a large postinfarction intervention trial. METHODS: We assessed the nature and severity of anginal symptoms and the use of antianginal and antiischemic interventions before enrollment in the 1842 men and 389 women with left ventricular ejection fractions less than or equal to 40 percent after an acute myocardial infarction who were randomized in the Survival and Ventricular Enlargement trial. RESULTS: Before their index infarction, women were as likely as men to have had angina and to have been treated with antianginal drugs. However, despite reports by women of symptoms consistent with greater functional disability from angina, fewer women had undergone cardiac catheterization (15.4 percent of women vs. 27.3 percent of men, P less than 0.001) or coronary bypass surgery (5.9 percent of women vs. 12.7 percent of men, P less than 0.001). When these differences were adjusted for important covariates, men were still twice as likely to undergo an invasive cardiac procedure as women, but bypass surgery was performed with equal frequency among the men and women who did undergo cardiac catheterization. CONCLUSIONS: Physicians pursue a less aggressive management approach to coronary disease in women than in men, despite greater cardiac disability in women.
The costs and clinical results of a thrombolytic therapy protocol using intravenous (IV) streptokinase in small community hospitals prior to emergency transfer for cardiac catheterization for possible percutaneous transluminal coronary angioplasty (PTCA) were prospectively studied in 56 patients with an acute myocardial infarction [Tulsa Heart Center-Myocardial Infarction Study Team (THC-MIST) protocol]. Findings were compared to those for 53 similar patients receiving "conventional therapy" during the same study period. The reperfusion rate for IV streptokinase was 63%. Additional emergency PTCA yielded a total reperfusion rate of 95%. Despite emergency cardiac catheterization for all THC-MIST patients, average hospital charges were not significantly different between the two groups ($20,495 vs. $20,722; THC-MIST vs. conventional therapy, respectively). Total charges (hospital plus physician fees) were also not significantly different ($22,986 vs. $22,400; THC-MIST vs. conventional therapy, respectively). Intensive care unit (ICU) days and total hospital stays were significantly less for THC-MIST patients (3.1 vs. 5.8 ICU days, p less than 0.05 and 8.8 vs. 12.4 hospital days, p less than 0.05; THC-MIST vs. conventional therapy, respectively). Thus initiation of IV streptokinase in community hospitals for acute myocardial infarction with subsequent transfer for possible PTCA can yield high reperfusion rates without significantly increasing health care costs.
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To assess the efficacy of a new calcium entry blocker, diltiazem (Cardizem), for prophylaxis of Prinzmetal's angina, 48 patients were studied in randomized, multiple crossover multiclinic study (2 weeks single-blind, 8 weeks double-blind). Diltiazem dosage in one crossover phase was 120 mg per day; in the other, 240 mg per day. Therapeutic response was measured by patients' diary records of angina frequency and nitroglycerin tablet consumption. Treatment with 120 mg of diltiazem per day reduced angina by 41 percent from the entry placebo period and 20 percent from the paired placebo period (p less than 0.005). Treatment with 240 mg of diltiazem per day reduced angina frequency by 68 percent from the entry placebo period and 43 percent from the paired placebo period (p less than 0.01). There were similar reductions in nitroglycerin consumption. Adverse experiences that may have been related to the medication were noted in only 5 percent of patients. There were no alterations in blood pressure or heart rate. The PR interval increased 3 percent at the 240 mg dosage level. We conclude that diltiazem is an effective and safe agent for control of symptoms of Prinzmetal's angina.
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Localized choroidal calcification was detected clinically in two otherwise healthy men. The lesions showed typical features of choroidal nevi. One patient exhibited features suggesting a drusen overlying the nevus. Echography detected choroidal calcification in both cases. A-scan echography revealed a highly reflective choroidal mass attenuating the ultrasound beam. B-scan ultrasonography revealed a dense choroidal mass attenuating the ultrasound beam with focal echoes remaining at low sensitivity. Orbital radiographic and CT scan examination confirmed the echographic findings.
Disagreement still exists regarding the influence of rosette formation, pseudorosettes, necrotic changes, vascularity, and calcification on the echographic characteristics of retinoblastoma. To further evaluate the echographic pattern of retinoblastoma confirmed by tissue diagnosis, we studied 11 consecutive cases of retinoblastoma and correlated pathologic findings with A- and B-scan echographic findings. In five patients with heavily calcified tumors, the A-scan echograms were more accurate in documenting reflectivity and revealed an extremely highly reflective pattern attenuating the ultrasonic beam substantially and casting characteristic shadows on the sclera. The B-scan echogram revealed a mass attenuating the ultrasound beam. This mass had dense focal echoes persisting at lower sensitivity within the tumor. In five patients with mild calcification on pathological examination, the A-scan echogram showed a highly reflective pattern. In one case with no calcification, the A-scan echogram revealed a medium reflective pattern. The B-scan echogram revealed a well-defined mass in each case. The degree of rosette differentiation, pseudorosettes, or necrosis failed to correlate with A-scan echographic pattern specific for retinoblastoma. No case showed a cystic appearance on B-scan echogram regardless of the degree of necrosis seen in the pathologic specimen. The echographic findings in retinoblastoma depend primarily on the degree of calcification and are not influenced independently by other specific pathologic characteristics of the tumors.
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Assessment of the pathophysiologic changes associated with systemic hypertension has been limited by difficulty in justifying invasive studies of the left ventricle. Echocardiography, because it is notinvasive, offers an attractive method of assessing cardiac dimensions and function in hypertensive heart disease. Fourteen age-matched normotensive subjects and 31 patients with hypertension (but without clinical evidence of coronary artery disease) were studied before receiving any antihypertensive therapy. The patients with hypertension were classified into three groups on the basis of previously established electrocardiographic and chest X-ray criteria: group I, normal electrocardiogram and chest roentgenogram (13 patients); group II, left atrial abnormality by electrocardiogram and a normal chest roentgenogram (8 patients); and group III, left ventricular hypertrophy by electrocardiogram or chest roentgenogram, or both (10 patients). Mean arterial pressure increased significantly from group I to group II and from group II to group III (P is less than 0.01), and this increase was associated with a similar progressive increase in left ventricular mass assessed with echocardiogram (P is less than 0.01). A significant increase was also found in both posterior wall and septal thickness in groups II (P is less than 0.05) and III (P is less than 0.01). In association with this increased mass a significant decrease in ejection fraction and fractional fiber shortening was demonstrated in groups II (P is less than 0.05) and III (P is less than 0.01) although cardiac index was reduced only in group III (P is less than 0.05). Thus, increased ventricular mass can be identified with echocardiography at an early stage of hypertensive heart disease when only left atrial abnormality is identifiable with electrocardiographic criteria and decreased left ventricular performance occurs with increasing arterial pressure and left ventricular hypertrophy.
Two infants had orbital cavernous hemangioma that showed impressive regression documented by ultrasound follow-up. In a 15-week-old infant the hemangioma regressed from a size of 11.49 mm to 5.36 mm in prominence during a six-month period. In a 9-month-old infant the mass regressed from 8.53 mm to 4.6 mm during a six-month period. These cases demonstrate that orbital cavernous hemangioma in infancy occasionally shows impressive regression. Furthermore, they illustrate the value of orbital ultrasonography in defining the natural history of orbital hemangioma. Similar follow-up studies in large numbers of infants with orbital hemangioma are needed to further our understanding of the natural history of this tumor.
Seven consecutive patients with Eisenmenber's syndrome, cared for by the obstetric team in conjunction with the cardiology service, were reviewed to assess the possible role of prophylactic heparin therapy and intensive care on the outcome of these patients. In each patient, the diagnosis of Eisenmenger's syndrome was established by the demonstration of equal pulmonary arterial and aortic pressures with a predominantly right-to-left shunt at cardiac catheterization. Five of the seven patients died as follows: Three patients died between the fifth and eighth post-partum days, one patient died during the twenty-sixth week of pregnancy, and one patient died on the fifth postoperative day following tubal ligation. All of these five patients received prophylactic heparin therapy. In three patients, heparin therapy was complicated by excessive bleeding during the postoperative or postpartum period. Autopsy examination in two patients revealed no evidence of thrombosis in the main pulmonary arteries and no pulmonary infarction, contrary to the antemortem clinical suspicion. The two survivors did not receive prophylactic heparin. They comprised one patient who had normal delivery and one patient who underwent tubal ligation and induction of abortion. We conclude that the prohibitive mortality rate of Eisenmenger's syndrome during pregnancy, puerpurium, or surgical procedures probably cannot be modified with prophylactic heparin therapy. Anticoagulant treatment does not prevent deterioration of patients and probably compounds the problem by causing significant bleeding.
Ventricular ectopic activity in a young person with an otherwise normal heart usually requires no treatment. In older patients, 10 or more ectopic beats per minute, multiform beats and ectopy occurring close to the preceding beat are indications for drug control. Exercise-induced ectopic beats may respond to physical training. Three or more consecutive ventricular ectopic beats constitute ventricular tachycardia, which requires prevention. Supraventricular tachyarrhythmias, when paroxysmal, may be aborted by maneuvers to enhance vagal tone. When they are frequent, treatment is required.
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We describe a 49 year old woman with impressive regression of renal artery stenosing atherosclerotic lesions in response to sustained excellent control of hyperlipidemia. Initially, she had high blood pressure necessitating combined drug therapy with chlorothiazide, methyldopa and propranolol, with only moderately satisfactory control. Renal arteriography revealed a 90 per cent stenosing lesion of the right renal artery and 75 per cent narrowing of the left renal artery. Peripheral vein plasma renin was markedly increased at 32 ng/ml. With a combination of cholestyramine and clofibrate, serum lipids were maintained at normal values for several years. Increased blood pressure diminished spontaneously, and the patient has maintained normal blood pressures after discontinuation of antihypertensive therapy. Repeat renal arteriograms showed almost complete regression of the right renal artery lesion and a possible decrease in left renal artery disease. Peripheral vein plasma renin became normal at 3 ng/ml. This case illustrates that sustained control of hyperlipidemia could lead to regression of atherosclerotic nodules and impressive clinical improvement in certain patients.
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