A graphic approach to normal placental development.
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Embryonic Development↗
Biomedical subjects
M C Cohen
Publications and source records attributed to M C Cohen.
New approaches to diagnosis and management of unstable angina and non-ST-segment elevation myocardial infarction.
Recently, it has been demonstrated in multiple clinical research studies that non-Q-wave myocardial infarction shares many of the features of unstable angina pectoris and that both diseases initially are managed similarly. Important new antiplatelet drugs (glycoprotein IIb-IIIa inhibitors) and antithrombin agents (low-molecular-weight heparin) are currently recommended for patients with unstable angina pectoris/non-ST-segment elevation MI who are at high or intermediate risk on the basis of symptoms, electrocardiographic findings, and the presence or absence of serum markers (eg, troponin I, troponin T, and creatine kinase-MB). This review provides important information concerning the results of clinical studies of glycoprotein IIb-IIIa inhibitors (tirofiban hydrochloride and eptifibatide) when used with unfractionated heparin in patients with this syndrome or with low-molecular weight heparin (enoxaparin sodium) in similar patients. The Thrombolysis in Myocardial Infarction IIIB, Veterans Affairs Non-Q-Wave Infarction Studies in Hospital, and Fast Revascularization During Instability in Coronary Artery Disease II studies evaluating a conservative, ischemia-guided approach vs an early aggressive approach to such patients are presented, with a practical algorithm for treating such patients.
Algorithms↗
Impact of diabetes on long-term survival after acute myocardial infarction: comparability of risk with prior myocardial infarction.
OBJECTIVE: To determine the effect of diabetes on long-term survival after acute myocardial infarction and to compare its effect with that of a previous myocardial infarction. RESEARCH DESIGN AND METHODS: In a prospective cohort study, we followed 1,935 patients hospitalized with a confirmed acute myocardial infarction at 45 U.S. medical centers between 1989 and 1993, as part of the Determinants of Myocardial Infarction Onset Study. Trained interviewers performed chart reviews and face-to-face interviews with all patients. We analyzed survival using Cox proportional hazards regression to control for potentially confounding factors. RESULTS: Of the 1,935 patients, 320 (17%) died during a mean follow-up of 3.7 years. A total of 399 patients (21%) had previously diagnosed diabetes. Diabetes was associated with markedly higher total mortality in unadjusted (hazard ratio [HR] 2.4; 95% CI 1.9-3.0) and adjusted (1.7; 1.3-2.1) analyses. The magnitude of the effect of diabetes was identical to that of a previous myocardial infarction. The effect of diabetes was not significantly modified by age, smoking, household income, use of thrombolytic therapy, type of hypoglycemic treatment, or duration of diabetes, but the risk associated with diabetes was higher among women than men (adjusted HRs 2.7 vs. 1.3, P = 0.01). CONCLUSIONS: Diabetes is associated with markedly increased mortality after acute myocardial infarction, particularly in women. The increase in risk is of the same magnitude as a previous myocardial infarction and provides further support for aggressive treatment of coronary risk factors among diabetic patients.
Aged↗
Age and history of cardiac disease as risk factors for cardiac complications after peripheral vascular surgery in diabetic patients.
OBJECTIVE: To examine the relationship of age and clinical factors to postoperative cardiovascular events in a cohort of diabetic patients undergoing peripheral vascular surgery. PATIENTS AND METHODS: In this cohort study, 316 diabetic patients were followed up prospectively after femoral-to-distal artery bypass surgery. The major end points of the study were all-cause mortality and cardiac morbidity (cardiac events defined as nonfatal myocardial infarction, unstable angina, and congestive heart failure). RESULTS: The overall postoperative cardiac event rate was 17.1% (54/316), with a 7.6% (24/316) rate of postoperative death or nonfatal myocardial infarction. Older diabetic patients (> or = 65 years) had a complication rate of 19.9% (43/216) compared with an 11.0% (11/100) complication rate in younger diabetic patients (< 65 years) (P = .02). Younger diabetic patients with a clinical history of coronary artery disease had an event rate of 18.2% (39/216) compared with an event rate of 2.4% (1/42) in younger diabetic patients without known cardiac disease (P = .02). In contrast, event rates were similar (20.7% [150/208] vs 18.2% [66/108]) in older diabetic patients with or without prior evidence of cardiac disease. CONCLUSION: Advanced age and clinical evidence of coronary artery disease are important determinants of postoperative outcome in diabetic patients undergoing peripheral vascular surgery.
Adult↗
The clinical and histological spectrum of esophagitis in pediatrics. Some keys to its links to gastritis.
UNLABELLED: The purpose of our study was to assess the clinical and histological spectrum of esophagitis, seeking possible links between esophagitis and gastritis particularly Helicobacter pylori-associated, in pediatric patients. MATERIAL AND METHODS: We retrospectively studied 66 sequential and 63 gastric biopsies from 66 patients fulfilling the histological diagnosis of "esophagitis". Cases were arranged in two groups: G1 (H. pylori negative): N = 44 (27 m; 17 f), mean age 7.3 y (range 7-9 m-18 y) and G2 (H. pylori positive): N = 22 (16 f; 6 m), mean age 12.8 y (range 7-16 y). RESULTS: The bases for performing endoscopy and biopsies were as follows: in G1 (N44) symptoms of gastroesophageal reflux (GER) in 24 cases and non-GER in 20 cases; in G2 (N = 22): symptoms of GER in 13 and non-GER in 9 cases. Esophageal endoscopic findings for G1 patients included: normal mucosa 39; esophagitis 3; congestive mucosa and esophagitis 1 each. Stomach endoscopic findings for G1 patients were normal mucosa 29; nodular antrum 7; congestive mucosa 4; ulceration 2; unknown 2. G2 children revealed nodular antrum 19; congestive antrum 2; normal mucosa 1. Histology of esophageal biopsies in G1 was esophagitis grade 1,35; grade 2,4; grade 3, 4, and grade 5, 1. G2 showed esophagitis grade 1,20, and grade 2,2. The histologic findings of the gastric biopsies were as follows: G1 (N = 41): normal mucosa 23; mild chronic gastritis 6; mucus depletion in the superficial 5; mild acute gastritis 3; hemorrhage 1; insufficient tissue 3. G2: chronic gastritis associated with H. pylori with or without follicular hyperplasia 21; mild gastritis 1.
Adolescent↗
[Focal atrophy with stellate scars in children with chronic gastritis associated to Helicobacter pylori. Is this early atrophic gastritis?].
BACKGROUND: Atrophic gastritis has not been described in children in the setting of Helicobacter Pylori infection. METHODS: Gastric biopsies of six children (7 to 11 years old) with history of HpCG and recent therapeutic eradication of H. Pylori, were reviewed. In the 6 H. Pylori was documented with histology, culture, direct visualization and/or serology before treatment. Cases were compared with five biopsies of age-matched patients showing none of the above-mentioned clinical data. All the biopsies were formalin-fixed, paraffin embedded and stained with hematoxilin-eosin, Masson trichrome and reticulin stain. RESULTS: The biopsies of the six treated patients showed variable-in-size stellate-shaped spots of glandular loss replaced by dense connective tissue with few inflammatory cells. The fibrous tissue showed a central area of scarring and radially oriented spikes extending to adjacent interglandular tissue, more evident with the Masson trichrome stain. Density of inflammatory cells in the lamina propria was variable. H. Pylori organisms were consistently absent. On the reticulin stain the atrophic areas showed coarser and compacted reticulin. Stellate scars were not present in the five controls. CONCLUSIONS: Small foci with fibrous scars may be found in children with long standing HpCG, perhaps as an early sequel of it. We hypothesize that if the chronic gastritis-gastric atrophy process is a continuum, these stellate scars may be representing the very beginning of the multifocal atrophic gastritis usually seen in adult patients.
Atrophy↗
Infusion versus bolus contrast echocardiography: a multicenter, open-label, crossover trial.
BACKGROUND: In current practice, contrast echocardiography is performed with single or multiple bolus injections, which often result in an uncontrolled period of attenuation followed by transient left ventricular opacification (LVO). Because a "slow bolus" appears to reduce attenuation and prolong LVO, we hypothesized that a controlled infusion of contrast might provide a more uniform contrast effect with less attenuation and longer contrast duration. METHODS AND RESULTS: We sought to test the hypothesis by using an infusion of contrast (DEFINITY [perflutren], The DuPont Pharmaceuticals Co, Medical Imaging, North Billerica, Mass) that is stable when diluted in saline in a randomized, multicenter, controlled, crossover trial. Sixty-four patients with poor noncontrast images were recruited at 3 centers and randomly assigned to 2 single "slow" bolus injections of contrast (10 microL/kg each over a period of 30 to 60 seconds) or an infusion (1. 3 mL in 50 mL normal saline initially at 4.0 mL/min) of contrast. Patients then returned within 24 to 72 hours for the alternative form of contrast delivery. Three independent experienced echocardiographers viewed 30 seconds of videotape for all optimal baseline and optimal contrast images to score LVO and qualitatively assessed endocardial border evaluability. The duration of adequate LVO then was independently assessed by review of the entire videotape. Three independent sonographers traced single-frame, digitally captured images to measure the length of the contiguous endocardial border visualized. Both bolus and infusion administration demonstrated improved LVO (>90% by all blinded readers, P <.01) and endocardial border visualized (mean increase of 1.8 to 4.7 cm at both end-diastole and end-systole, all P <.05) as compared with baseline images. However, contrast infusion resulted in a longer duration of LVO (range of mean durations for each reader, 158 to 174 seconds longer, P <.05) and a shorter duration of attenuation (18 to 54 seconds, P <.05) compared with either bolus injection. There were no severe adverse events with contrast infusion. CONCLUSIONS: Contrast echocardiography delivered as an infusion optimizes the contrast effect by decreasing the attenuation period, extending the LVO duration, and providing a uniform contrast effect that may be useful in obtaining multiple echocardiographic views, stress echocardiography, myocardial perfusion imaging, and applications in which blood flow must be quantified.
Adult↗
MRI changes in myocarditis--evaluation with spin echo, cine MR angiography and contrast enhanced spin echo imaging.
AIM: Myocarditis is probably under-diagnosed with clinical criteria generally used for diagnosis. Magnetic resonance imaging (MRI) has shown promise in detecting heart muscle disorders and we set out to assess the role of cine magnetic resonance angiography (MRA) and contrast enhancement in myocarditis, as there is a need for a non-invasive tool that can aid prognosis and follow-up. MATERIALS AND METHODS: Twenty patients were evaluated with T1 SE pre- and post-gadolinium enhancement and cine MRA. Four patients were histologically proven to have myocarditis, eight others were diagnosed as having myocarditis by clinical criteria and eight did not have myocarditis. Images were evaluated in a blinded fashion for regional wall motion abnormality and contrast enhancement pattern. Analysis of contrast enhancement by signal intensity measurement was also performed. RESULTS: Focal myocardial enhancement with associated regional wall motion abnormality correlated with myocarditis in 10 out of 12 patients, two patients with abnormal focal enhancement alone also clinically had myocarditis. None of the non-myocarditis patients showed abnormal focal enhancement. Enhancement analysis suggests that focal corrected myocardial enhancement of > 40% is abnormal. CONCLUSION: In the correct clinical context, focal myocardial enhancement on spin echo MRI strongly supports a diagnosis of myocarditis, especially when associated with regional wall motion abnormality.Roditi, G. H. (2000). Clinical Radiology55, 752-758.
Adult↗
Sulfomucins in Helicobacter pylori-associated chronic gastritis in children: is this incipient intestinal metaplasia?
BACKGROUND: Little is known about early stages of intestinal metaplastic in chronic gastritis. The purpose of this study was to determine the presence of sulfated mucosubstances hence most probably intestinal metaplasia, in isolated cells of surface gastric pits, and glands in pediatric patients with Helicobacter pylori-associated chronic gastritis. METHODS: Participants were nine patients (nine different biopsies; mean age 11.5 years, range 3-16 years) with sulfomucin-containing cells evident in the gastric biopsy specimen. Eight of the patients were selected from a group of 15 patients with histologically documented H. pylori-associated chronic gastritis in whom the utility of the Sydney system was being tested. RESULTS: Symptoms and endoscopic findings of H. pylori-associated chronic gastritis were the same regardless of the presence or absence of sulfomucin-containing cells. On hematoxylin and eosin stained tissues, neither intestinal metaplasia nor atrophy was apparent. However, periodic acid-Schiff (PAS)-alcian blue (pH 1.0) stain revealed the presence of sulfated mucosubstances in isolated cells of gastric pits and glands in the nine patients. CONCLUSIONS: This finding may represent a "minimal" form of incomplete intestinal metaplasia (type III). Because the nine patients had been untreated, the change is probably reversible. Two follow-up biopsies in patients in whom H. pylori had been treated and eradicated showed absence of sulfated mucins. Although these findings cannot be regarded as fully developed type III intestinal metaplasia, it is possible that left untreated, the alteration may persist and evolve into some other complication. This conclusion justifies follow-up of these patients.
Adolescent↗
Behavioral medicine in medical education: report of a survey.
Behavioral medicine has become increasingly important in medical education over the past two decades, but adoption of its principles and methods has been slow. Behavioral medicine stresses the effects of human behavior on health and illness using a biopsychosocial approach. It also focuses on the use of the doctor-patient relationship, which, if developed using appropriate communication skills, can result in greater patient satisfaction and increased compliance. The authors surveyed all 124 American medical schools to assess both national trends and specific efforts in the teaching of behavioral medicine principles and methods. A review of the types of behavioral medicine programs offered reveals that eight percent of U.S. medical schools had integrated programs of behavioral medicine. Several successful and effective programs were identified, as were a number of specific curricular components. There are several options available to medical schools to integrate behavioral medicine into medical education. The authors conclude that medical education must include behavioral medicine in order to improve the health of the public and to meet the demands of a changing health care system.
Behavioral Medicine↗
Assessment of the Sydney System in Helicobacter pylori-associated gastritis in children.
OBJECTIVE: The aim of our study was to establish the usefulness of the Sydney System in grading H. pylori-associated chronic gastritis in biopsies from pediatric patients. STUDY DESIGN: Fifteen children (average age: 10.8 years) with histologically-proven gastritis were studied. Classification and grading of gastritis were performed according to the analogue visual scales described in the updated version of the Sydney System. A chart was specially designed to record the morphological grading in this study. Altogether, we studied 79 gastric biopsies. RESULTS: Neutrophilic infiltrates were absent in 27 biopsies, mild in 35, and moderate in 17. This feature was not marked in any of the biopsies. Mononuclear infiltrates were mild in 38 biopsies, moderate in 36, and marked in 5. Density of H. pylori was mild in 39 biopsies, moderate in 27, and marked in 2. In three post-treatment biopsies belonging to the same patient, no H. pylori was observed. Additional 8 biopsies (7 from the body and 1 from the antrum) showed no H. pylori, although organisms were simultaneously present in other stomach sites. Lymphoid follicles were present in 19/79 biopsies. Intestinal metaplasia was not seen on slides stained with hematoxylin-eosin (HE). However, the Alcian blue-PAS stain revealed isolated positive cells in 8 out of 15 patients. None of the gastric biopsies showed mucosal atrophy. CONCLUSION: The results show that the Sydney System is applicable for pediatric patients in case of H. pylori-associated gastritis. However, the number of biopsies recommended in the Sydney System seems excessive for this age group.
Adolescent↗
Long-term prognostic value of preoperative dipyridamole thallium imaging and clinical indexes in patients with diabetes mellitus undergoing peripheral vascular surgery.
The objective of this study is to assess the prognostic impact of preoperative dipyridamole thallium imaging and clinical variables on the long-term outcome of diabetic patients undergoing peripheral vascular surgery. Complete follow-up was obtained in 101 consecutive patients with diabetes mellitus undergoing routine dipyridamole thallium scintigraphy before vascular surgery (mean 4.2 +/- 3.2 years, range 1 month to 11 years). Low risk was defined by diabetes alone with a normal resting electrocardiogram. High risk was defined as a history of angina, myocardial infarction, congestive heart failure, or resting electrocardiogram abnormalities. There were 71 deaths in 98 patients discharged alive from the hospital (median survival 4.4 years). Age, the presence of resting electrocardiogram abnormalities, and an abnormal thallium scan were independent predictors of late death. After adjusting for age >70 years and thallium abnormalities, high-risk patients had a death rate 4.8 times (95% confidence interval 1.7 to 13.4, p <0.002) greater than low-risk patients. The presence of >2 reversible thallium defects was useful in further risk stratification of both low- and high-risk patients. Low-risk patients with >2 reversible defects had a median survival of 4.0 years compared with 9.4 years in those with < or =2 reversible defects (p <0.001). Similarly, high-risk patients with < or =2 reversible defects had an intermediate median survival rate of 4.7 years compared with 1.8 years in the group with >2 reversible defects (p <0.001). Therefore, advanced age and the presence of resting electrocardiographic or thallium abnormalities identifies a subset of diabetic patients with a poor long-term outcome after vascular surgery. Combined clinical and thallium variables may identify a population in whom intensive medical or surgical interventions may be warranted to reduce both perioperative and late cardiac events.
Aged↗
Metastatic pulmonary calcification with ossification in a child with acute lymphoblastic leukemia.
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Calcinosis↗
Stress testing: national patterns and predictors of test ordering.
OBJECTIVE: To determine predictors of ordering of exercise stress tests. BACKGROUND: Because exercise stress testing is routinely used and widely available and may have an effect on subsequent evaluation of and therapy for heart disease, understanding current patterns of ordering exercise stress tests may have important implications for national health care costs. We hypothesized that factors other than clinical condition exert an influence on ordering of exercise stress tests. METHODS: Data from the 1991 and 1992 National Ambulatory Medical Care Surveys conducted by the National Center for Health Statistics were analyzed by means of multivariate logistic regression. RESULTS: In an estimated 1.12 billion adult visits to office-based physicians in the United States (95% confidence interval [CI], 1.07-1.16 billion), 6.2 million (95% CI, 4.8-7.6 million) exercise stress tests were ordered. After adjustment for clinical and nonclinical variables associated with the office visit, cardiologists were 3.7 (95% CI, 2.7-5.1) times more likely to order exercise stress tests than were internists, who were more likely to order an exercise stress test than were family and general practitioners (0.5, 95% CI, 0.3-0.7). Nonclinical factors associated with increased ordering of exercise stress tests included male sex (odds ratio 2.5; 95% CI, 2.0-3.2), white race (odds ratio 1.6; 95% CI, 1.1-2.3), new referral status (odds ratio 3.8; 95% CI, 2.5-5.8), and private insurance (odds ratio 1.4; 95% CI, 1.1-1.8). Medicare recipients were about half (95% CI, 0.4-0.9) as likely as other patients to have an exercise stress test ordered. CONCLUSIONS: Factors other than clinical condition exert an influence on ordering of exercise stress tests and may represent modifiable elements associated with appropriate practice.
Adult↗
Rapidly reversible cardiomyopathy associated with chronic ipecac ingestion.
Ipecac, an over-the-counter emetic agent, has been a drug of choice for abuse by patients with eating disorders. Its alkaloid emetine has been associated with serious cardiac toxicity; however, the dose effect has not been well established. We present a patient with anorexia and bulimia nervosa who ingested ipecac chronically and developed the characteristic manifestations of ipecac toxicity. Unexpectedly, her induced left ventricular dysfunction returned to normal after only 10 days of withholding the drug. This finding, in contrast with the findings of other reports, establishes that ipecac cardiomyopathy can be readily reversible. The cumulative experience thus far, nonetheless, provides no discernible pattern of the effect of ipecac on the myocardium. Thus, in the continuum of poisoning, the point at which the myocardium becomes irreversibly damaged is undetermined. With continued abuse, potentially lethal outcome, and limited experience with ipecac cardiotoxicity, further investigation and perhaps heightened restriction of the drug are warranted.
Adult↗
Nonuniform nighttime distribution of acute cardiac events: a possible effect of sleep states.
BACKGROUND: Although 250,000 myocardial infarctions and 38,000 sudden cardiac deaths occur at night annually, this public health problem is underappreciated and poorly understood. We examined whether the incidence of myocardial infarction, sudden cardiac death, and automatic implantable cardioverter-defibrillator (AICD) discharge was nonuniform, a result that may implicate physiological triggers such as sleep-state dependent changes in autonomic nervous system activity. METHODS AND RESULTS: We conducted a review of the circadian pattern of the onset of myocardial infarction (n=19), sudden cardiac death (n=12), and AICD discharge (n=7). The nighttime period was chosen a priori as midnight to 5:59 AM. These reports documented 11,633 nocturnal myocardial infarctions (20% of the total myocardial infarctions), 1981 nocturnal sudden cardiac deaths (14.6% of the total sudden cardiac deaths), and 1200 nocturnal AICD discharges (15.0% of the total discharges). The distributions of myocardial infarction, sudden cardiac death, and AICD discharge were each significantly nonuniform (P<.001). The peak incidence of myocardial infarction and AICD discharge occurred between midnight and 0:59 AM, whereas the peak incidence of sudden cardiac death was between 1:00 and 1:59 AM. The trough in incidence occurred between 4:00 and 4:59 AM for sudden cardiac death and between 3:00 and 3:59 AM for myocardial infarction and AICD discharge. CONCLUSIONS: Nocturnal myocardial infarction, sudden cardiac death, and AICD discharge exhibit nonuniform distributions. This finding is consistent with the hypothesis that sleep-state dependent fluctuations in autonomic nervous system activity may trigger the onset of major cardiovascular events and provides further impetus for more directly testing this hypothesis at population, individual, and mechanistic levels. A better understanding of nocturnal triggers may make it possible to reduce the incidence of myocardial infarction, ventricular tachyarrhythmias, and sudden cardiac death during the nocturnal period.
Circadian Rhythm↗
Meta-analysis of the morning excess of acute myocardial infarction and sudden cardiac death.
To evaluate the impact of elimination of the morning peak of cardiovascular events, we performed a meta-analysis of studies of circadian variation of myocardial infarction and sudden cardiac death. The impact would be significant because approximately 1 of every 11 acute myocardial infarctions and 1 of every 15 sudden cardiac deaths are attributable to the morning excess incidence.
Circadian Rhythm↗
Cytologic characteristics of peripheral neuroectodermal tumors in fine-needle aspiration smears: a retrospective study of three pediatric cases.
Cytologic diagnosis of peripheral neuroectodermal tumors (PNT) on fine-needle aspiration (FNA) smears represents a challenge to the cytopathologist. Usually ancillary studies are used to achieve definitive diagnosis. We retrospectively examined FNA material from three cases of PNT with the aim of identifying their features. Positive and negative cytologic findings were recognized. Positive features for PNT included the presence of: rather uniform appearance of the cells, which display scant but almost always-present perinuclear clear cytoplasm (suggesting a bland epithelial tumor); nuclei with distinctively smooth nuclear membrane contour, finely granular chromatin, and one or two small nucleoli (suggesting neuroendocrine anlage); and organization of the cells singly or in cohesive clusters. Negative findings included the absence of: frequent mitotic figures, large nucleoli, nuclear pleomorphism, cellular debris, histiocytes, and polymorphonuclear leucocytes. The smears appeared clean, with small, uniform cells having features suggesting a neuroendocrine epithelial tumor. These findings may prove useful for accurate cytologic diagnosis and differentiation of PNT from other small blue round cell tumours (SBRCT) of soft tissues without the use of ancillary studies since, when properly evaluated, cytomorphology of the latter group of tumors is more heterogeneous than generally believed.
Abdominal Muscles↗