Biomedical subjects
Publications and source records attributed to N Brooks.
This paper reviews the psychological deficits found after head injury. The deficits are very broadly of two types involving cognitive and behaviour disturbances. The main features of the two types of disturbances are described; and the natural history, prediction, functional impact, and rehabilitation of the disturbances are reviewed. Key features of good clinical evaluation of patients are identified.
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Twenty active amateur boxers were studied seeking evidence of neurological dysfunction and, if present, the best method for detecting it. Seven of these boxers had an abnormal clinical neurological examination, eight an abnormal EEG and nine of 15 examined had abnormal neuropsychometry. The CT scan was abnormal in only one. An abnormal clinical examination correlated significantly (p less than 0.05) with an increasing number of fights, and an abnormal EEG with decreasing age (p less than 0.05). In several of the neuropsychometric tests, the boxers were significantly worse than controls (p less than 0.05). Neuropsychometry was the best method for detecting neurological dysfunction.
Neuropsychological examinations were carried out on 29 amateur boxers and 19 controls matched for age, ethnicity, and education. There was no evidence of significantly impaired performance in the boxers. Within the boxing group, a variety of features of boxing history were examined as possible predictors of cognitive performance (such as number of knockouts, duration of boxing). No feature was a significant predictor of lower cognitive performance.
Infection is a rare complication of cardiac mural thrombus and may prove difficult to diagnose and treat. We describe a patient with infected thrombus associated with a left ventricular aneurysm, involving Salmonella typhimurium. Cross-sectional echocardiography proved helpful in establishing the diagnosis.
A patient with a dissecting thoracic aortic aneurysm presented with acute low output cardiac failure due to right atrial obstruction. Five years earlier she had had her aortic valve replaced because of aortic regurgitation. Obstruction of the superior vena cava and pulmonary artery has been reported elsewhere as a complication of compression by thoracic aortic dissecting aneurysm. This case was unusual in presenting as right atrial obstruction.
Twenty nine patients who had had refractory supraventricular tachycardia were studied 4-36 (mean 16) months after transvenous fulguration of the atrioventricular junction. Twenty two had complete atrioventricular block, five partial atrioventricular block, and two had atrioventricular conduction via an accessory atrioventricular pathway. Though all patients were free of palpitation after the procedure, exertional dyspnoea had developed in 13 and in two patients pre-existing dyspnoea had worsened. During ventricular demand pacing, exercise time was reduced to 43% of the predicted value for their age and sex. The 16 patients with rate responsive pacemakers demonstrated a significantly better but still impaired exercise capacity during "physiological" pacing as compared with their performance during constant rate pacing. In patients with complete atrioventricular block there was an increase in spontaneous ventricular rate during exercise in seven patients and in response to the Valsalva manoeuvre in eight patients. This suggests that the intrinsic ventricular pacemaker is influenced by autonomic nervous system activity in some patients. It is concluded that though transvenous fulguration is successful in controlling tachycardia it may reduce exercise capacity. Most patients remain in complete atrioventricular block after the procedure and, in contrast with the practice as described in early reports, would benefit from "physiological" pacing--though even with this mode exercise capacity is likely to be abnormal.
A close relative of each of 42 severely head injured patients was interviewed at 5 years after injury, following initial study at 3, 6, and 12 months. Persisting severe deficits, in some cases worse than at 1 year, were primarily psychological and behavioural, although minor physical deficits, for example in vision, were also common. Relatives were under great strain; significantly more so than at 1 year. The best predictor of strain in the relative was the magnitude of behavioural and personality change in the patient.
Treatment with the combination of aspirin and dipyridamole is believed to reduce the incidence of coronary vein graft occlusion. A double blind randomised controlled trial was carried out in which aspirin 990 mg and dipyridamole 225 mg daily or placebo were added to the routine postoperative management (warfarin for three months) of 320 patients undergoing coronary bypass grafting. The trial treatment was given for 12 months, after which the results were assessed by coronary and graft angiography. The two randomised groups, each of 160 patients, were comparable in age, sex, symptomatic state, angiographic findings, and operative procedure. Repeat coronary arteriography was carried out on 266 patients, 133 in each group. All grafts and distal anastomoses were patent in 68% (91/133) of the placebo patients and in 75% (100/133) of those receiving active treatment. Overall graft patency was 87% (306/352) and 89% (342/385) respectively. Retrospective subgroup analysis showed patency rates of 72% (26/36) and 78% (39/50) of grafts to vessels requiring preliminary endarterectomy, and 80% (36/45) and 91% (40/44) of distal anastomoses to vessels measured at operation to have a diameter of less than or equal to 1 mm. None of these differences was significant at the 5% level. Thus in this group of patients with high graft patency rates, treatment with aspirin and dipyridamole conferred no appreciable advantage.
A 17 year old girl had a myocardial infarction. Three days later coronary angiography showed an occlusive thrombus in the circumflex and anterior descending arteries. The coronary arteries themselves appeared to be normal, and this was confirmed at repeat angiography three months later. Tests of haemostasis showed a deficiency of factor XII.
A retrospective study was carried out of the outcome of 102 patients who underwent a second operation for myocardial revascularisation, necessitated by persistence or recurrence of intractable angina after their first coronary bypass procedures. Operative mortality was 2%. During follow up of the survivors (mean interval 36.4 months) five died, two after further operation, and five underwent further surgery. Sixty eight patients reported an improvement in their symptoms, 57 of whom claimed to have little or no angina. Less favourable results were recorded for those patients reviewed with longer follow up. No useful indicators of prognosis were identified. The problem of angina in patients who have already received bypass grafts is likely to increase as more revascularisation surgery is performed. Reoperation offers a reasonable prospect of helping some of these patients, but not all will be suitable. Their long term prognosis remains uncertain.
Between January 1979 and December 1981, 142 patients undergoing surgery to the right coronary artery agreed to have repeat coronary arteriography one year later. Thirty patients underwent combined endarterectomy and bypass grafting to the right coronary artery. The patency of these grafts was compared with that of grafts in 69 patients undergoing direct grafting to the right coronary artery and in 43 with grafting to the posterior descending coronary artery. There were two hospital deaths and one late death. No patients developed new inferior Q waves on the electrocardiogram. Repeat coronary arteriography at one year showed that 21 (72%) of the 29 grafts were patent after combined endarterectomy and bypass grafting to the right coronary artery. Sixty three (94%) grafts to the right coronary artery and 40 (93%) grafts to the posterior descending coronary artery were patent at one year. Direct grafts to the right coronary artery or its posterior descending branch had a significantly higher patency rate at one year than grafts to the endarterectomised right coronary artery. Graft patency after the combined procedure correlated with the extent of atherosclerosis in the posterior descending coronary artery. It was not influenced by treatment with platelet antagonists. Endarterectomy of the right coronary artery was most successful when it allowed a single graft to perfuse both the large posterior descending and left ventricular branches.
A pilot study of the wives of 19 coronary artery surgery patients assessed levels and predictors of affective symptoms. A substantial proportion of wives (40 to 50%) reported levels of depression (but not anxiety) severe enough to warrant treatment, and many attributed this to the effects of their husband's operation. Neither the wives' expectations of patient outcome, nor the objectively assessed surgical outcome bore any relationship to the wives' affective state. A previous psychiatric history in a wife was possibly related to her affective state, but her 'N' score (emotionality) on the Eysenck Personality Questionnaire was very strongly related to her state.
In 60 consecutive patients undergoing vein graft surgery the angiographic appearances of the coronary vessels were compared with those of the vessels at operation. On the basis of lumen diameter at the potential sites for grafting it was possible to predict with reasonable accuracy from examination of the angiogram which vessels were large enough to be grafted. Angiographic predictive accuracy was 82% and was similar both for vessels which filled normally and for those which filled by collaterals. The predictive value of the angiographic assessment was similar for branches thought to be too small (predictive value 74%) and for those considered sufficiently large (predictive value 85%) to receive a vein graft. Disease of the vessel walls was found at surgery (66% of coronary branches examined) more frequently than was predicted from the angiographic appearances (33%). Previous necropsy studies have found a high prevalence of coronary atheroma in the population, yet normal angiographic appearances in the coronary arteries are not uncommon in patients undergoing investigation for suspected coronary disease. The present study showed that atheroma may be present in coronary vessels without encroaching into the vessel lumen, so that it is not evident on the angiogram. Coronary atheroma is thus present more often and is more widely distributed in the coronary tree than is indicated by coronary angiography.
The heart rate/ST slope was evaluated in 49 patients undergoing routine investigation for possible coronary artery disease. The slope correctly predicted the absence of any 75% stenoses in the seven patients to whom this applied; it was, however, correct for only four of 30 with one stenosis, one of 10 with two, and neither of the patients with three. Distinct slope ranges were not found, and the previously published ranges said to be specific for no significant stenosis and one, two, and three vessel disease were not.
We compared Hexabrix 320 (580 mOsm kg-1) with Conray 420 (2500 mOsm kg-1) for left ventriculography using a prospective randomised double-blind protocol. One hundred consecutive patients with suspected coronary disease were assigned to Hexabrix (52) or Conray (48) for left ventriculography (dose 10 ml m-2 BSA; flow rate 12 ml s-1). Thirteen patients found Hexabrix unpleasant compared with 24 receiving Conray; overall the feelings of warmth and discomfort were less with Hexabrix than Conray (p less than 0.01 and p less than 0.02 respectively). The incidence of nausea, vomiting, and hypersensitivity was similar. Angiographic quality was better with Conray than with Hexabrix (p less than 0.05). Average changes in heart rate and systolic pressure were similar, though there was greater variation in systolic pressure change after Conray (p less than 0.025). End diastolic pressure increased more after Conray than after Hexabrix (p less than 0.05). These slight advantages of Hexabrix over Conray may be valuable in patients requiring multiple angiograms or in those with impaired cardiac function, but do not justify its use for routine angiography.
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