Biomedical subjects
Publications and source records attributed to L Cotter.
Anabolic steroids have been associated with a variety of adverse reactions, including myocardial infarction. We report two cases of myocardial infarction in young men on anabolic steroids. In both men, extensive intracoronary thrombosis was demonstrated at coronary angiography; this failed to resolve despite anticoagulation.
Ninety consecutive patients who were admitted to hospital with acute chest pain were followed-up five years later. At the time of the original admission, all of the patients received a detailed physical and psychiatric evaluation. Seventy-one patients were diagnosed as having ischaemic heart disease, and 19 were diagnosed as having nonspecific chest pain. Patients with nonspecific pain were younger, consumed greater amounts of alcohol, smoked more than their organic counterparts, and were more likely to suffer from psychiatric disorder. The five-year assessment was carried out using a self-report questionnaire. Of the original 71 patients with ischaemic heart disease, 14 had died; 43 questionnaires were returned, 80.2% of the original sample. Sixteen (84.9%) of the patients with nonspecific pain were followed up; none had died. Both groups were predominantly male. The patients with nonspecific pain still smoked more than the patients with ischaemic heart disease, and they had significantly more symptoms of anxiety. The overall prevalence of psychiatric morbidity remained high, however, in both groups. Patients who had psychiatric illness at the time of the original assessment were more anxious at follow-up and more likely to complain of chest pain than those who had been well. Patients with nonspecific chest pain continued to seek treatment on a regular basis from their general practitioners either for chest pain or for other symptoms, but few were in frequent contact with hospital services. The possible preventive effects of psychiatric intervention at an earlier stage in both groups of patients needs to be investigated.
We studied the outcome of permanent pacing in those with a history suggestive of Stokes-Adams attacks but no electocardiographic evidence of bradyarrhythmia. Of 11 patients who fulfilled pre-defined inclusion criteria, over a mean follow-up period of 5.4 years, seven patients were free of symptoms and two were much improved following pacing. We suggest that in those with a clinical history of frequently recurrent Stokes-Adams attacks and a normal electrocardiogram, pacemaker insertion may be a reasonable course of action.
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One hundred and eight consecutive patients admitted urgently for the first time with chest pain were interviewed to assess psychiatric symptoms prior to admission, at admission and three months later. Seventy-one patients had ischaemic heart disease, 19 had non-specific chest pain and 18 patients were excluded because of other organic causes for the pain. Compared to the ischaemic heart disease subjects, the non-specific chest pain patients tended to have more psychiatric disorder which increased over the three assessments; at follow up 33% of ischaemic heart disease patients and 59% of non-specific chest pain patients had psychiatric disorder. Chest pain was reported by 71% of the non-specific group at three months but this was not related to presence of psychiatric disorder. Unlike previous studies which 'have assessed out-patients with normal coronary angiograms', this study has shown that males predominate among patients admitted urgently with non-specific chest pain. In addition, these subjects use greater amounts of cigarettes and alcohol, and experience significantly more psychiatric disorder compared to patients admitted with ischaemic heart disease. The factors which lead to some of these patients developing chronic non-specific chest pain need to be investigated in further studies.
DC cardioversion is a safe, simple procedure for the management of patients with tachyarrhythmias. Its great advantages in an emergency are its immediate effect and the avoidance of the potential side effects of drug therapy. It should be considered in the management of any patient with a tachyarrhythmia.
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Information technology is of increasing importance to the health service. Two main types of system have grown up, those in clinical departments and central administrative systems. It is important to consider their inter-relationships. A clinical system in the Renal Unit at Manchester Royal Infirmary is described, which is typical of many departmental systems. Further work is reported demonstrating an impressive commonality in the requirements of different clinical disciplines and supporting the view that departmental systems are a valuable source of accurate management data. The experience gained from designing departmental systems is reviewed. It is concluded that the participation of users is essential to the successful design and implementation of systems in the National Health Service and that departmental systems have a crucial role to play in the development of district information systems.
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Digitised M mode echocardiograms were analysed in 22 patients with possible Björk-Shiley mitral prosthetic dysfunction. Patients with paraprosthetic mitral regurgitation had a significantly greater shortening fraction, an increased peak rate of dimension change during systole, and an increased peak velocity of circumferential fibre shortening than those with poor left ventricular function. Patients with a clotted prosthesis had lower values for shortening fraction and peak rate of dimension change during systole than patients with paraprosthetic regurgitation. In this latter group, the peak rate of dimension change during diastole and peak lengthening rate were greater than in either those patients with poor left ventricular function or those with a clotted prosthesis. In addition, the peak lengthening rate was greater in those with a clotted prosthesis than in those with poor left ventricular function. Thus M mode echocardiography is a useful method of assessing mitral prosthetic dysfunction and allows patients with paraprosthetic regurgitation to be distinguished from those with either poor left ventricular function or a clotted prosthesis.
Variables of haemostatis were studied in 21 men, aged less than 50 years, with confirmed coronary artery disease but without severe hyperlipidaemia and in 21 healthy controls. Fibrinogen concentrations were significantly raised in the patients, 10 (48%) of whom also showed defective fibrinolysis in response to a standard stress test. These findings suggest that hypercoagulability may be important in the aetiology of some cases of early onset coronary artery disease.
A case of giant aneurysm of the membranous interventricular septum which presented as a mediastinal mass is described. Aneurysms of the membranous septum are rare and usually found incidental to the main cause of the patient's complaints. They are most commonly associated with ventricular septal defects but can also be found in the presence of ventriculoarterial discordance, atrioventricular canal defects, and semilunar valve abnormalities. In patients presenting with a mediastinal mass which may be cardiac, full left and right heart catheterisation are necessary; a simple right heart study is inadequate.
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Six patients with early systolic closure of the aortic valve are described with mitral regurgitation, double outlet right ventricle, left ventricular diverticulum, congestive cardiomyopathy, Eisenmenger ventricular septal defect, and aortic regurgitation with an aneurysmal ascending aorta, respectively. None had evidence of subaortic stenosis. Early sytolic closure of the aortic valve is thus not diagnostic of subvalvular aortic stenosis but is a non-specific finding.
A patient is described in whom extreme right ventricular hypoplasia and right-to-left shunting through an atrial septal defect occurred after relief of severe pulmonary stenosis. The ability of the hypoplastic right ventricle to deal with an increased volume load was assessed at cardiac catheterisation by occluding the atrial septal defect with a balloon tipped catheter.
Diazoxide was injected into the pulmonary artery in nine patients with primary pulmonary hypertension. There was no significant change in pulmonary artery pressure, which fell by more than 10 mmHg in only two patients. The pulmonary blood flow increased in all patients as a result of a fall in pulmonary vascular resistance (by 4 to 17 units). Systematic vasuclar resistance also fell as expected in all patients. Oral diazoxide was given to seven patients, two of whom showed sustained clinical improvement while remaining on treatment (400 to 600 mg daily). Five patients were unable to tolerate the drug, because of nausea and sickness (two), peripheral oedema requiring large doses of diuretics (four), diabetes (three), and postural hypotension (one). Hirsutes was troublesome in the two patients remaining on treatment. Diazoxide may be useful in the management of some patients with primary pulmonary hypertension, but its use is limited by the frequency of side effects. Our results suggest that examination of othe potent vasodilators may be worth while.
Early systolic closure of the aortic valve (ESC) is a non-specific echocardiographic finding which occurs in a wide range of conditions such as hypertrophic (obstructive) cardiomyopathy (HCM), fixed subaortic stenosis, ventricular septal defect with and without Eisenmenger reaction, mitral regurgitation, aortic root dissection, double outlet right ventricle, ruptured right sinus of valsalva aneurysms, diverticulum of the left ventricle, congestive cardiomyopathy and even in normals. When ESC occurs in the presence of clinical features of left ventricular outflow tract obstruction it raises the strong possibility of a subvalvular lesion but its absence does not exclude any of the form of sub-valvular stenosis. When ESC occurs in hypertrophic cardiomyopathy it is likely that an intra-ventricular pressure gradient is presented, but gradients can be found in the absence of ESC and the degree of ESC does not correlate with the size of any such gradient. ESC is not always present in fixed sub-aortic stenosis, neither the presence nor the degree of ESC correlates with the pressure gradient. It does not permit differentiation between the three types of fixed subaortic stenosis as it may occur in any of them. ESC is almost certainly caused by alteration in the pattern of blood flow in the aortic root, although the factors which influence the patterns of flow are imperfectly understood and merit further study.
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