Biomedical subjects
Publications and source records attributed to E Amsterdam.
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OBJECTIVE: To determine whether isosorbide-5-mononitrate (IS-5-MN), an active metabolite of isosorbide dinitrate, when given twice daily (in the morning and 7 hours later), prevents development of tolerance and reduction in exercise performance or is associated with a rebound increase in anginal attacks in patients with stable angina pectoris. DESIGN: Multicenter, placebo-controlled, parallel-group, double-blind, randomized study. SETTING: Four university teaching hospitals and five private cardiology outpatient clinics. PATIENTS: 116 patients with stable exertional angina who stopped treadmill exercise because of angina pectoris. INTERVENTION: After stopping all antianginal drugs with the exception of beta-blockers, patients received single-blind placebo for 1 week followed by either 20 mg of IS-5-MN (n = 60 patients) or placebo (n = 62 patients) twice daily at 0800 hours and 1500 hours for 2 weeks. MEASUREMENTS: Serial symptom-limited exercise tests and patients' diaries recording activity and date, time, and severity of anginal attacks. RESULTS: Compared with placebo recipients, patients receiving IS-5-MN walked significantly longer at 2, 5, and 7 hours after the 0800-hour dose (P < 0.01) and at 2 and 5 hours after the 1500-hour dose (P < 0.01). Before the morning (0800-hour) dose, exercise duration increased by 0.53 minutes in placebo recipients and by 0.85 minutes in those receiving IS-5-MN therapy (P = 0.10). Neither nocturnal nor early-morning anginal attacks increased during IS-5-MN therapy compared with placebo. Headaches occurred in 19 (32%) patients in the IS-5-MN group and in 9 (15%) patients in the placebo group but necessitated discontinuation of treatment in only 2 (3%) patients in the IS-5-MN group. CONCLUSION: Isosorbide-5-mononitrate, 20 mg twice daily given 7 hours apart, was well tolerated and improved exercise performance for 7 hours after the morning dose and for 5 hours after the afternoon dose without evidence of development of pharmacologic tolerance. No rebound increase in anginal attacks was found.
A 49-year-old man with a history of traumatic left above-elbow amputation was hospitalized for surgical management of a phantom pain syndrome. Evaluation revealed a history of exertional chest pain radiating into the phantom limb. Exercise testing reproduced the pain symptoms and demonstrated electrocardiographic ischemic S-T segment depression. Coronary angiography revealed severe three-vessel coronary artery disease. The patient underwent coronary artery bypass graft surgery which eliminated the anginal component of his phantom pain syndrome and abolished evidence of exercise-induced myocardial ischemia. This case illustrates that myocardial ischemia can produce phantom pain with the characteristics of typical angina and indicates the need for thorough evaluation of patients presenting with unusual features of phantom pain.
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Consecutive admissions to a university hospital coronary intensive care unit were prospectively evaluated using a modified version of the Structured Clinical Interview for DSM-III-R by interviewers blind to the patient's cardiac status. Panic disorder was present in almost one-third of the patients. Four (21%) of the 19 patients with panic disorder also had positive cardiac findings, including 2 who had myocardial infarctions. Of the 27 patients with negative cardiac findings, 15 (55.5%) had panic disorder. Whereas panic disorder and coronary heart disease may coexist in patients with acute chest pain, there appears to be a very high prevalence of panic disorder among patients in whom cardiac disease has been excluded.
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Histologically proved Paget's disease of the breast with negative hormonal receptor assay in a 73-year-old man induced a review of the 27 valuable cases of the literature. Our patient is disease-free, eight years after treatment by modified radical mastectomy and adjuvant irradiation. Peak incidence of the disease is between 50 and 70 years of age. The most frequent presenting signs reported are ulcerations and eczematous lesions of the nipple (71.4%) with discharge and bleeding in 39.3% of the cases. Other findings are a palpable mass (42.8%) and involved axillary lymph nodes (53.5%). The treatment of choice is shown to be radical or modified radical mastectomy with adjuvant radiotherapy. To date, no proof exists of the value of hormone receptors assays and routine adjuvant hormone therapy is not practiced.
A review of 100 women over 70 years of age treated for breast carcinoma is reported. The short- and long-term results of treatment were evaluated with a median follow up of 4.7 years. Due to our aggressive approach, only 11% of this group died from breast cancer, and the 5-year survival rate was 51%, including all stages of the disease. The result of this study indicates that elderly women with breast cancer should be treated by surgical methods that offer the best chance of cure, regardless of patient's age.
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Between 1970 and 1982, 147 patients were operated on for obstructing carcinoma of the colon at our institution. Of these, 25 patients with obstructing carcinoma of the left side of the colon were treated by emergency primary resection with colocolostomy. Three patients who had primary resection died postoperatively, two of them from myocardial infarction and one, a 66 year old patient with liver metastasis, from sepsis. One patient had an anastomotic leak and underwent a proximal diverting colostomy. Results of this form of treatment have been good, and we advocate the procedure for selected groups of patients.
A case of cystosarcoma phyllodes in a 10 year-old, prepubertal white female is reported. In spite of the common belief of hormonal dependency of this tumor, hormonal receptor assays were negative. The diagnosis, behaviour and treatment of this unusual lesion is discussed.
An analysis of 205 episodes of bleeding encountered during a 7 year period by the staff of a surgical service has been described. Of 168 postoperative bleeding episodes, 80 were associated with anticoagulant or antiaggregant treatment, 51 were caused by technical error, and 37 were associated with sepsis. Of 18 hemorrhages after invasive procedures, 12 were associated with anticoagulants. In the whole series, in 33 of 111 episodes in patients receiving antithrombotic drugs, there was some deviation from standard accepted protocols. Bleeding occurred in the surgical wound or at the site of operation or puncture in 154 instances. Some of the bleeding episodes, especially at other sites, presented in an unusual manner and posed a diagnostic problem. Bleeding was responsible for death or contributed to death in 11 patients, and in 32 patients, it caused operation or reoperation. Other short- and long-term morbidity was also caused. As in many complications, prevention is of the essence.
The prophylactic antianginal efficacy of nitroglycerin (NTG) oral spray was assessed in 20 patients with angiographically documented coronary disease and stable angina pectoris. The evaluation was by a randomized crossover trial involving treadmill exercise testing. On study day 1, a control treadmill exercise test was performed, followed 30 minutes later by a second exercise test 2 minutes after administration of either placebo (group A, 10 patients) or NTG spray 0.8 mg (group B, 10 patients). One week later, on study day 2, the patients again underwent control treadmill exercise testing followed by a second exercise test after either NTG spray (group A) or placebo (group B). NTG spray delayed the onset of anginal pain during exercise by a mean of 100 +/- 64 seconds (p less than 0.001) in 13 patients and prevented pain entirely in seven. Placebo did not significantly delay the appearance of angina and prevented chest pain in only one patient. NTG spray increased treadmill exercise duration by 31% before the onset of angina (p less than 0.001); placebo did not significantly alter the duration of exercise. NTG spray abolished in six patients and delayed in 14 patients the onset of exercise-induced ST-segment depression of 1 mm (p less than 0.001). Patients achieved a higher heart rate at peak exercise with NTG spray, and yet the maximal exercise-induced ST-segment depression of 2.1 +/- 1.0 mm during the control study declined to 1.3 +/- 0.9 mm on NTG spray (p less than 0.001). Placebo had no effect on exercise ST-segment depression. These data indicate that the oral NTG spray is an effective prophylactic for exercise-induced angina.
The achievement of satisfactory ambulatory therapy of severe chronic congestive heart failure may be helped by the development of safe and orally effective cardiotonic agents. Therefore, we evaluated by cardiac catheterization and limb plethysmography the temporal cardiocirculatory responses of the new ingestible beta agonist pirbuterol in 10 coronary heart disease patients with severe congestive heart failure refractory to digitalis and diuretics. After a single oral dose of 0.4 mg/kg, ventricular dysfunction was considerably improved during 6 hours of hemodynamic monitoring. Cardiac index increased from a control of 1.7 l/min/m2 to 2.6 l/min/m2 (p < 0.001) at 1 hour and to 2.4 l/min/m2 (p < 0.005) at 3 hours and was 2.2 l/min/m2 (p < 0.001) at 6 hours; left ventricular filling pressure decreased from a control of 24 mm Hg to 19 mm Hg (p < 0.005) at 1 hour and to 18 mm Hg (p < 0.005) at 3 hours and was 22 mm Hg (p < 0.05) at 6 hours. Concomitantly, the peak increment in heart rate (6 beats/min) was minimal and without ectopy and mean arterial blood pressure decreased only 10 mm Hg. total systemic vascular resistance declined by 887 dyn-sec-cm-5, forearm venodilation occurred and the rate-pressure product was unaltered. Thus, oral pirbuterol provides beneficial hemodynamic effects in patients with severe left ventricular dysfunction and appears potentially useful for long-term management of low-output congestive heart failure.
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