Search PubMed⌕ Search

Biomedical subjects

R D Murray

Publications and source records attributed to R D Murray.

At least 37 records · Page 2Linked to original sources
PubMed2001

Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation.

BACKGROUND: The conventional treatment strategy for patients with atrial fibrillation who are to undergo electrical cardioversion is to prescribe warfarin for anticoagulation for three weeks before cardioversion. It has been proposed that if transesophageal echocardiography reveals no atrial thrombus, cardioversion may be performed safely after only a short period of anticoagulant therapy. METHODS: In a multicenter, randomized, prospective clinical trial, we enrolled 1222 patients with atrial fibrillation of more than two days' duration and assigned them to either treatment guided by the findings on transesophageal echocardiography or conventional treatment. The composite primary end point was cerebrovascular accident, transient ischemic attack, and peripheral embolism within eight weeks. Secondary end points were functional status, successful restoration and maintenance of sinus rhythm, hemorrhage, and death. RESULTS: There was no significant difference between the two treatment groups in the rate of embolic events (five embolic events among 619 patients in the transesophageal-echocardiography group [0.8 percent]) vs. three among 603 patients in the conventional-treatment group [0.5 percent], P=0.50). However, the rate of hemorrhagic events was significantly lower in the transesophageal-echocardiography group (18 events [2.9 percent] vs. 33 events [5.5 percent], P=0.03). Patients in the transesophageal-echocardiography group also had a shorter time to cardioversion (mean [+/-SD], 3.0+/-5.6 vs. 30.6+/-10.6 days, P<0.001) and a greater rate of successful restoration of sinus rhythm (440 patients [71.1 percent] vs. 393 patients [65.2 percent], P=0.03). At eight weeks, there were no significant differences between the two groups in the rates of death or maintenance of sinus rhythm or in functional status. CONCLUSIONS: The use of transesophageal echocardiography to guide the management of atrial fibrillation may be considered a clinically effective alternative strategy to conventional therapy for patients in whom elective cardioversion is planned.

Aged↗
PubMed2001

Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation.

Electrical cardioversion of patients with atrial fibrillation (AF) is frequently performed to relieve symptoms and improve cardiac performance. Patients undergoing cardioversion are treated conventionally with therapeutic anticoagulation for three weeks before and four weeks after cardioversion to decrease the risk of thromboembolism. A transesophageal echocardiography (TEE)-guided strategy has been proposed as an alternative that may lower stroke and bleeding events. Patients without atrial cavity thrombus or atrial appendage thrombus by TEE are cardioverted on achievement of therapeutic anticoagulation, whereas cardioversion is delayed in higher risk patients with thrombus. The aim of this review is to discuss the issues and controversies associated with the management of patients with AF undergoing cardioversion. We provide an overview of the TEE-guided and conventional anticoagulation strategies in light of the recently completed Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) clinical trial. The two management strategies comparably lower the patient's embolic risk when the guidelines are properly followed. The TEE-guided strategy with shorter term anticoagulation may lower the incidence of bleeding complications and safely expedite early cardioversion. The inherent advantages and disadvantages of both strategies are presented. The TEE-guided approach with short-term anticoagulation is considered to be a safe and clinically effective alternative to the conventional approach, and it is advocated in patients in whom earlier cardioversion would be clinically beneficial.

Anticoagulants↗
PubMed2001

Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy.

This study assesses how the newer modalities of tissue Doppler echocardiography and color M-mode flow propagation compare with respiratory variation of Doppler flow in distinguishing between constrictive pericarditis and restrictive cardiomyopathy. We studied 30 patients referred for further evaluation of diastolic function who had a diagnosis of constrictive pericarditis or restrictive cardiomyopathy established by diagnostic tests, including clinical assessment, magnetic resonance imaging, cardiac catheterization, endomyocardial biopsy, and surgical findings. Nineteen patients had constrictive pericarditis and 11 had restrictive cardiomyopathy. We performed 2-dimensional transesophageal echocardiography combined with pulsed-wave Doppler of the pulmonary veins and mitral inflow with respiratory monitoring, tissue Doppler echocardiography of the lateral mitral annulus, and color M-mode flow propagation of left ventricular filling. Respiratory variation of the mitral inflow peak early (peak E) velocity of > or =10% predicted constrictive pericarditis with 84% sensitivity and 91% specificity and variation in the pulmonary venous peak diastolic (peak D) flow velocity of > or =18% distinguished constriction with 79% sensitivity and 91% specificity. Using tissue Doppler echocardiography, a peak early velocity of longitudinal expansion (peak Ea) of > or =8.0 cm/s differentiated patients with constriction from restriction with 89% sensitivity and 100% specificity. A slope of > or =100 cm/s for the first aliasing contour in color M-mode flow propagation predicted patients with constriction with 74% sensitivity and 91% specificity. Thus, the newer methods of tissue Doppler echocardiography and color M-mode flow propagation are equivalent and complimentary with Doppler respiratory variation in distinguishing between constrictive pericarditis and restrictive cardiomyopathy. The additive role of the new methods needs to be established in difficult cases of constrictive pericarditis where respiratory variation may be absent or decreased.

Adult↗
PubMed2001

The diagnosis of growth hormone deficiency (GHD) in successfully treated acromegalic patients.

Due to persistent qualitative abnormalities in GH secretion following treatment, and lack of a sensitive marker of GHD in mid-adult life it is extremely difficult to diagnose GHD in treated acromegalic patients. The diagnosis of GHD in patients with pituitary disease relies on provocative tests of GH reserve. Arginine releases GH by reducing somatostatin inhibition of GH release, whereas GH secretagogues (GHS) affect GH release by direct stimulation of the GHS receptor, though an intact GH releasing hormone (GHRH) axis is a prerequisite. The peak GH response to insulin-induced hypoglycaemia and arginine in acromegalic patients, in whom basal serum GH levels of less than 5 mU/l have been achieved, is greatly diminished in those treated by hypothalamo-pituitary irradiation. We aimed to study the response of successfully treated acromegalic patients to the growth hormone secretagogue hexarelin in view of its different putative mechanism of action, and in addition, to determine whether it has any value in the diagnosis of GH deficiency in this subset of patients. Nineteen acromegalic patients, in whom mean serum GH levels below 5 mU/l have been achieved through treatment, were recruited. Eight of the patients had been treated by surgery alone (Group A) and 11 had received primary or postoperative irradiation (Group B). All patients underwent 20 min blood sampling to provide a 24-h GH profile. Serum IGF-I was measured from a sample drawn between 0900 h and 1000 h. On a second visit arginine 20 g/m2 was infused over 30 min, blood samples were taken before commencing the infusion and at 30-min intervals thereafter for 180 min. At the final visit hexarelin 1.5 mcg/kg was administered as an intravenous bolus at t = 0. Blood was drawn at 15-min intervals from - 30 to 180 min. All patients in group A showed an increment in serum GH following hexarelin (DeltaGHHEX) > 20 mU/l, a normal response to arginine, and a mean 24-h GH > 0.5 mU/l. In group B only 4/11 achieved a DeltaGHHEX > 20 mU/l, 5/11 producing a response of < 2 mU/l. Four of the five patients with a DeltaGHHEX < 2 mU/l were also demonstrated to have a mean 24-h GH of < 0.5 mU/l and serum IGF-I SDS < + 0.5. All four patients in Group B who achieved a DeltaGHHEX > 20 mU/l, were observed to show an absent or minimal GH response to arginine. Despite loss of the GH response to arginine, the DeltaGHHEX is retained in a proportion of those patients in whom "safe" GH levels were achieved following irradiation. From the putative mechanisms of action of these provocative agents a plausible explanation would be that the GHRH axis is more resilient than endogenous somatostatin-secreting neurones to radiation-induced damage. Furthermore, GH secretagogues may have a role, in combination with serum IGF-I levels, in the diagnosis of GH deficiency in treated acromegaly.

Acromegaly↗
PubMed2001

Right atrial spontaneous echo contrast and thrombi in atrial fibrillation: a transesophageal echocardiography study.

BACKGROUND: Previous studies have reported the clinical and echocardiographic findings of patients with left atrial spontaneous echo contrast (SEC) and thrombi. We sought to study these characteristics in patients with right atrial SEC and thrombi. METHODS: We reviewed 580 consecutive patients from the ACUTE (Assessment of Cardioversion Using Transesophageal Echocardiography) Registry and found 79 patients (14%, aged 67 +/-13 years, 67 male) with transesophageal echocardiography (TEE) findings of right atrial SEC or thrombi (group 1). This group was compared with a control group of 75 consecutive patients (group 2) (aged 68 +/- 13 years, P = not significant; 49 male, P <.005) from the registry with no TEE findings of SEC or thrombi in the left or right atrium. RESULTS: Atrial fibrillation was present in 60 of 79 group 1 patients (76%). Five right atrial (6%) and 11 left atrial (14%) thrombi were identified. Both left ventricular ejection fraction (39% +/- 16% versus 47% +/- 14%; P =.0005) and presence of right ventricular dysfunction (n = 44 versus 18; P =.0001) differed significantly between groups 1 and 2, respectively. Right atrial area (24 +/- 6 cm(2) versus 22 +/- 6 cm(2); P = .02) was larger in patients in group 1. Left atrial SEC was present in 68 of 79 group 1 patients (86%). Patients with right atrial thrombi and right atrial SEC had a longer duration of arrhythmia (524 +/-812 days versus 147 +/-368 days, P <.05) than patients with right atrial SEC only. CONCLUSIONS: Right atrial SEC has a prevalence of 14% in patients with atrial arrhythmia who undergo TEE-guided cardioversion. Right atrial thrombi are a rare finding and were seen in fewer than 1% (5/580) of patients with atrial arrhythmia. Right atrial thrombi among patients on anticoagulation therapy were not associated with clinically significant pulmonary embolism.

Adult↗
PubMed2001

Potential clinical efficacy and cost benefit of a transesophageal echocardiography-guided low-molecular-weight heparin (enoxaparin) approach to antithrombotic therapy in patients undergoing immediate cardioversion from atrial fibrillation.

An alternative clinical management strategy and cost analysis model is presented for patients with atrial fibrillation of >2 days' duration who may benefit from immediate cardioversion with self-administered low-molecular-weight heparin (enoxaparin) as a bridge antithrombotic therapy to warfarin, after a negative transesophageal echo-cardiography (TEE) screening for thrombus. Assuming no difference in stroke or bleeding rates, our cost minimization model shows that the TEE-guided enoxaparin treatment costs are $1353 lower per patient than an intravenous unfractionated heparin approach. Sensitivity analyses for stroke and bleeding reveal that the treatment-cost economic dominance of the TEE-guided enoxaparin approach may be enhanced by an expected improvement in clinical outcome.

Anticoagulants↗
PubMed2001

Organized sports for children and preadolescents.

Participation in organized sports provides an opportunity for young people to increase their physical activity and develop physical and social skills. However, when the demands and expectations of organized sports exceed the maturation and readiness of the participant, the positive aspects of participation can be negated. The nature of parental or adult involvement can also influence the degree to which participation in organized sports is a positive experience for preadolescents. This updates a previous policy statement on athletics for preadolescents and incorporates guidelines for sports participation for preschool children. Recommendations are offered on how pediatricians can help determine a child's readiness to participate, how risks can be minimized, and how child-oriented goals can be maximized.

Age Factors↗
PubMed2000

National use of the transesophageal echocardiographic-guided approach to cardioversion for patients in atrial fibrillation.

Transesophageal echocardiographic (TEE)-guided cardioversion of patients in atrial fibrillation (AF) of >2 days' duration is used as an alternative to conventional therapy. The purpose of this study was to investigate practice patterns employed for stroke prophylaxis in patients with AF who underwent cardioversion, and to determine the relative use of conventional and TEE-guided management strategies. We forwarded regionally stratified survey questionnaires to 947 clinical practices within the United States. The 10-question questionnaire queried demographic and clinical practice volumes and practices for managing patients with AF who underwent cardioversion. In addition, we used historical data to determine longitudinal use patterns of the TEE-guided approach for a large institution over 7 years. The 197 completed and returned surveys yielded a return rate of 20.8%. The TEE-guided approach was employed in approximately 12% of total cardioversions, but 75% of practices indicated that they employed transesophageal echocardiography only occasionally. The TEE-guided approach was associated with community size (r = 0.19; p<0.008), type of practice (r = 0.26; p = 0.001), total use of transesophageal echocardiography (r = 0.48; p<0.001), and volume of cardioversions (r = 0.28; p<0.001). Importantly, there was little consensus on the most appropriate clinical indications for TEE-guided cardioversions, and the proportions of TEE-guided cardioversion to total number of electrical cardioversions remained stable over 7 years. Practice volume and physician training may be the most important variables in the adoption of the TEE approach.

Ambulatory Care↗
PubMed2000

Pre-treatment IGF-I level is the major determinant of GH dosage in adult GH deficiency.

OBJECTIVE: Severe GH deficiency in adults is a definite clinical entity, the effects of which can be reversed by administration of subcutaneous recombinant GH. The ideal dosing regimen and determinants of the maintenance dose have, however, yet to be elucidated. PATIENTS: In an open study of GH replacement we treated 65 GH-deficient adults of mixed adult- and childhood-onset, of mean age 35.5 (range 17-72) years, and comprising 38 females and 27 males, using an individualized low-dose titration regimen aimed at normalization of the serum IGF-I and induction of clinical improvement. RESULTS: Before initiation of GH therapy, median IGF-I SD was significantly lower in female than male patients (- 3.3 vs. - 1.9, P = 0.007) and in childhood-onset compared with adult-onset patients (- 3.9 vs. - 2.0, P < 0.001). Once maintenance dosage had been achieved, the median GH requirement was significantly greater in female than male patients (1.6 vs. 0.8 IU/day, P = 0.013) and childhood-onset compared with adult-onset patients (1.6 vs. 0.8 IU/day, P = 0.019). The median maintenance GH dose for the cohort overall was 1.2 (range 0.4-2.4) IU/day. By univariate analysis a significant negative correlation was observed between the maintenance GH dose and baseline IGF-I SD (r = - 0.63, P < 0.001). No significant correlation was demonstrated between maintenance GH dose and either age or weight. Multiple linear regression analysis using age, gender, weight, time of onset of GH deficiency, peak GH to the insulin tolerance test (ITT) and baseline IGF-I SD as independent variables demonstrated baseline IGF-I SD to account for 51% of the variation in GH dose required to normalize the IGF-I SD (P < 0.001). Those patients with the lower IGF-I SD at initiation of GH therapy required the greater GH dose. None of the other variables studied significantly influenced the maintenance dose. CONCLUSION: We have demonstrated that the GH dose required in an individual is dependent on the serum IGF-I SD before commencement of replacement. In contrast, the severity of GH deficiency as judged by the peak GH response to an ITT was unrelated to the maintenance GH requirement. The effect of age, gender and age at onset of GH deficiency on the final GH dose are accounted for by the lower pretreatment IGF-I SD in young, female and childhood-onset patients relative to older, male and adult-onset patients, respectively.

Adolescent↗
PubMed2000

Transesophageal echocardiography guided enoxaparin antithrombotic strategy for cardioversion of atrial fibrillation: the ACUTE II pilot study.

BACKGROUND: Patients with atrial fibrillation >2 days' duration for whom immediate cardioversion is desired or required are commonly hospitalized for 4 or more days of antithrombotic therapy with intravenous unfractionated heparin and commencement of oral warfarin. For these early cardioversion patients, self-administered low-molecular-weight heparin (enoxaparin sodium) as "bridge" therapy to warfarin may obviate the need for hospitalization and activated partial thromboplastin time monitoring and thus potentially lower costs and enhance utility. OBJECTIVE: To compare feasibility and safety of a transesophageal echocardiography (TEE)-guided enoxaparin strategy with those of a TEE-guided unfractionated heparin strategy in patients with atrial fibrillation of >2 days' duration undergoing early electrical or chemical cardioversion. DESIGN AND SETTING: This is a randomized, multicenter clinical trial at 11 hospitals in the United States. PATIENTS AND INTERVENTION: Two hundred patients with atrial fibrillation >2 days' duration requiring early chemical or electric cardioversion will be enrolled. TEE-guided intravenous unfractionated heparin bridge therapy will be compared with TEE-guided subcutaneous enoxaparin bridge therapy. OUTCOME MEASURES: Feasibility outcomes are time to hospital discharge, patient quality of life/utility, treatment costs, and sinus rhythm. Safety outcomes are ischemic stroke, transient ischemic attack, systemic embolization, major and minor bleeding, clinical hemodynamic instability, and cardiac and cardioversion-related death for a 5-week period from enrollment. CLINICAL IMPLICATIONS: The results of this pilot study will have important clinical and economic implications for the antithrombotic management of patients with atrial fibrillation undergoing TEE-guided cardioversion.

Anticoagulants↗
PubMed2000

Reversal of the pattern of respiratory variation of Doppler inflow velocities in constrictive pericarditis during mechanical ventilation.

BACKGROUND: Spontaneous inspiration causes a characteristic decrease of the mitral valve (MV) and pulmonary venous (PV) flow velocities obtained by Doppler echocardiography in patients with constrictive pericarditis (CP). This has been explained by the decrement it causes in the intrathoracic pressure. Positive pressure ventilation (PPV) causes an increment of intrathoracic pressure with mechanical inspiration. Therefore the pattern of respiratory variation produced during PPV may differ from that seen during spontaneous breathing. OBJECTIVE: Our goal was to describe the effect of PPV on the pattern and magnitude of respiratory variation of MV and PV flow velocities in CP. METHODS: We performed intraoperative pulsed Doppler transesophageal echocardiography on 15 patients (13 men, mean age 52+/-15 years) with CP after general anesthesia and before sternotomy and pericardial stripping. The peak velocity and time-velocity integral (TVI) of the mitral inflow E and A waves and the PV systolic and diastolic waves were measured at onset of inspiration and expiration for 3 to 6 respiratory cycles. Respiratory phase was monitored with a heat-sensitive nasal thermistor. The percent change in Doppler flow velocities from mechanical inspiration (INS) to mechanical expiration (EXP) was calculated with the formula %change = INS - EXP / INS x 100. RESULTS: The peak velocity of the mitral inflow E wave was significantly higher during mechanical inspiration than expiration (57 +/-14.5 versus 47+/-13.9 cm/s, P<.001). This represented a percent change of 18%+/-7.9% from expiration to inspiration. The mean TVI of the mitral inflow E was also higher during mechanical inspiration than expiration (P = .02). The peak velocity of the PV D wave was higher during mechanical inspiration than expiration (39+/-17.8 versus 28+/-14.7 cm/s, P<.001). This represented a mean percent change of 28%+/-13.8%. The mean value of the TVI for the PV D wave was also significantly greater during mechanical inspiration than expiration (P <.05). CONCLUSIONS: Positive pressure ventilation reverses the pattern of respiratory variation of the MV and PV flow velocities in CP. The percent change in the peak velocities of the MV and PV flows produced by PPV is the same range reported in CP during spontaneous breathing.

Adult↗
PubMed2000

Clinical presentation of PCOS following development of an insulinoma: case report.

A 24 year old woman presented with a prolonged clinical history of fasting and exertional hypoglycaemia, and was subsequently diagnosed with an insulinoma. Concurrent symptoms of oligomenorrhoea and hyperandrogenism of similar duration were noted. Biochemically, hyperinsulinaemia was observed in association with a raised serum luteinizing hormone (LH), raised testosterone and androstendione concentrations. Surgical removal of the insulinoma resulted in resolution of the clinical and biochemical features of the polycystic ovarian syndrome (PCOS) but minimal change was observed in the ovarian ultrasound appearances. This case demonstrates the role of insulin in mediating the hypersecretion of both LH and androgens in women with polycystic ovaries. We suggest that hyperinsulinaemia converted occult 'polycystic ovaries' to become clinically manifest as 'polycystic ovary syndrome'. This paradigm has clear implications for women with insulin dependent diabetes mellitus who presumably have systemic hyperinsulinaemia.

Adult↗
PubMed2000

Growth hormone: current and future therapeutic applications.

The increased availability of growth hormone (GH) in the mid-1980s, as a result of advances in recombinant DNA techniques, has allowed research into the use of this hormone at physiological dosage, as replacement therapy for adults with GH deficiency (GHD) and at pharmacological dosages as a possible therapeutic agent, for a number of disease states. GHD adults have increased body fat and reduced muscle mass and consequently, reduced strength and exercise tolerance. In addition, they are osteopenic, have unfavourable cardiac risk factors and impaired quality of life. In these individuals, replacing GH reverses these anomalies, although it may not alter the reduced insulin-sensitivity. A proportion of adults with GHD perceive a dramatic improvement in their well-being, energy levels and mood following replacement. GH has protein and osteoanabolic, lipolytic and antinatriuretic properties. GH has been considered for the therapeutic treatment of frailty associated with ageing, osteoporosis, morbid obesity, cardiac failure, major thermal injury and various acute and chronic catabolic conditions. Initial small, uncontrolled studies for many of these clinical problems suggested a beneficial effect of GH, although, later placebo-controlled studies have not observed such dramatic effects. Furthermore, with a recent publication demonstrating an approximate 2-fold increase in mortality in critically ill patients receiving large doses of GH, the use of GH should remain in the realms of replacement therapy and research, until there are significant advances in our understanding.

Aging↗
PubMed1999

Effects of age and physiologic variables on right ventricular filling dynamics in normal subjects.

The reference values for right ventricular (RV) filling of normal persons and the effects of physiologic variables in a large series have not been described. The objective of this study was to characterize superior vena cava, hepatic vein, and RV inflow Doppler measurements in a large normal reference group to reflect the aging process, gender, heart rate, and effects of respiration. We prospectively performed pulsed-wave Doppler echocardiography of the superior vena cava, hepatic vein, and RV inflow during inspiration, expiration, and apnea in 115 healthy volunteers (62 women and 53 men) ranging in age from 21 to 84 years (mean +/- SEM 48 +/- 17). For analysis, the study subjects were classified by age into 2 groups: those < 50 years of age (group 1; n = 60) and those > or = 50 years of age (group 2; n = 55). Multiregression models were used to assess the influence of age, gender, and heart rate on Doppler variables. There were important differences in superior vena cava and RV inflow between the 2 groups. Group 2 had a greater superior vena cava peak atrial flow velocity (16 +/- 3 vs 13 +/- 3 cm/s), flow integrals (1.5 +/- 0.4 vs 1.1 +/- 0.3 cm), and reverse flow as a percentage of forward flow (17 +/- 6% vs 14 +/- 6%) than group 1. In group 2, peak RV inflow early filling velocity (41 +/- 8 vs 51 +/- 7 cm/s) and ratio of early filling-to-atrial filling (1.3 +/- 0.4 vs 2 +/- 0.5) were lower than that of group 1. Likewise, peak atrial filling velocity was higher (33 +/- 8 vs 27 +/- 8 cm/s) and deceleration time was longer (198 +/- 23 vs 188 +/- 22 ms) in group 2. The superior vena cava and hepatic vein peak forward flow velocities were significantly higher during inspiration than during expiration and apnea. Similarly, RV inflow velocities were significantly higher during inspiration than in expiration and apnea. Multiregression analysis showed that age, gender, and heart rate had important effects on Doppler variables. Thus, this study demonstrates the effects of aging and normal physiologic variable flow velocities in the superior vena cava, hepatic veins, and RV inflow in a large series of normal subjects.

Adult↗
PubMed1999

Role of transesophageal echocardiography in assessing diastolic dysfunction in a large clinical practice: a 9-year experience.

BACKGROUND: Two-dimensional transthoracic echocardiography with respiratory monitoring has been used to characterize diseases that impair diastolic function. Transesophageal echocardiography (TEE) has emerged as a complementary technique to evaluate patients with these diseases. The purpose of this study was to evaluate in a large clinical practice the utility of TEE with respiratory monitoring for classification of patients with diastolic dysfunction. METHODS: Over a 9-year period TEE was used to examine 192 patients referred to an echocardiography laboratory for additional evaluation of abnormal diastolic function. We performed pulsed-wave Doppler TEE of the left ventricular inflow and pulmonary veins and respiratory monitoring to categorize patients as showing restrictive physiologic features, constriction with or without effusion, mixed constriction and restriction, abnormal relaxation, pseudonormalization, large pericardial effusion or tamponade, or normal diastolic function. RESULTS: Patients with diastolic dysfunction underwent 3% of the total number of transesophageal studies conducted during the study period. Among the 192 patients referred for TEE, abnormal diastolic function was found in 181 (94%); 11 (6%) had normal diastolic function. Seventy-one (39%) of the 181 patients had restrictive physiologic features. Constrictive pericarditis was found in 54 (30%) of the patients and was confirmed for all 31 patients who underwent pericardiectomy. Mixed constriction and restriction was present in 21 (12%) of the patients. The other 35 patients (19%) had abnormal relaxation, pseudonormalization, or large pericardial effusion or tamponade. The cause of diastolic dysfunction was idiopathic for 32% of the patients, previous cardiac operation for 26%, cardiac amyloidosis for 23%, radiation therapy for 11%, and hypertension or advanced ischemic heart disease for 8%. CONCLUSION: Two-dimensional and Doppler TEE with respiratory monitoring is useful in categorizing patients with impaired diastolic function, primarily into those with restrictive physiologic features or constrictive pericarditis.

Adult↗
PubMed1999

Is cyclic vomiting syndrome related to migraine?

OBJECTIVE: To examine the overlap between cyclic vomiting syndrome (CVS) and migraine by comparing 2 subsets of children with migraine-associated and non-migraine-associated CVS. METHODS: We studied all children <18 years of age who met the consensus criteria for CVS after presentation to our pediatric gastroenterology service from 1986 to 1998. The clinical patterns and responses to treatment were obtained from a combination of chart reviews and structured interviews. RESULTS: Among 214 children identified as having CVS, 82% were classified as having migraine-associated CVS based on 1 of 2 criteria either a family history of migraines or subsequent development of migraine headaches. Compared with the non-migraine CVS subgroup, the migraine subset had milder episodes (20.7 27.3 SD vs 39.5 66.5 emeses/episode, P =.006); more symptoms of abdominal pain (83% vs 66%), headache (41% vs 24%), social withdrawal (40% vs 22%), photophobia (36% vs 16%, all P <.05); more frequent triggering events (70% vs 49%, P =.013) including psychologic stress (39% vs 22%), physical exhaustion (23% vs 3%), and motion sickness (10% vs 0%); and a higher positive response rate to anti-migraine therapy (79% vs 36%, P =.002). CONCLUSIONS: The majority of children with CVS were subclassified as having migraine-associated CVS. The migraine-associated subgroup had less severe vomiting, manifested symptoms typical of migraine headaches, and had higher response rates to anti-migraine therapy. These findings strengthen the relationship between migraine and CVS.

Child↗
PubMed1999

The effects of bovine respiratory syncytial on normal ovine lymphocyte responses to mitogens or antigens in vitro.

In the present study peripheral blod mononuclear cells (MNC) obtained from normal uninfected lambs were used to study the possible effects of bovine respiratory syncytial virus (BRSV) on lymphocyte responses to the mitogens, phytohaemagglutinin (PHA), concanavalin A (Con A) and pokeweed mitogen (PWM) in vitro. Live BRSV had a depressive effect on the proliferative responses of normal MNC to PHA, Con A and PWM. Inactivated BRSV and a commercial preparation of prostaglandin E2 were also found to depress the proliferative responses of normal ovine MNC to PHA but recombinant tumour necrosis factor-alpha (TNF-alpha) had no such effect. Serum samples obtained from BRSV-infected lambs contained substances inhibitory to PHA-driven lymphocyte blastogenesis. Memory blastogenic responses to border disease virus (BDV) of lymyphocytes obtained from lambs previously primed with BDV were significantly reduced when lymphocytes were exposed to infectious BRSV.

Animals↗