Malignant transformation of an ovarian mature cystic teratoma presenting as a rectal mass

BACKGROUND

Squamous cell carcinoma arising from malignant degeneration of a mature cystic teratoma is rare with a reported incidence of approximately 1-3%. The most common presenting symptoms are lower abdominal pain and increasing abdominal girth of several months' duration. Approximately 50% of the patients present with FIGO stage I while 35-38% present with stage III diseases.

CASE

The case described herein represents an unusual presentation and initial diagnostic dilemma of locally aggressive squamous cell carcinoma arising in an ovarian dermoid cyst, with invasion into the distal rectum and anal canal causing rectal bleeding similar to the presentation of anal squamous cell carcinoma. Despite aggressive surgical management with posterior exenteration and optimal tumor debulking followed by 5040-cGy pelvic radiation utilizing 25-MV photons, the patient developed pelvic recurrence at the vaginal cuff 6 weeks after completion of her adjuvant radiotherapy. She subsequently failed cis-platinum single-agent chemotherapy and died 9 months after her initial surgery and diagnosis.

CONCLUSION

Squamous cell carcinoma in the anal canal, diagnosed by colonoscopy or proctoscopy, could be an unusual presentation of that arising from malignant degeneration of an ovarian dermoid cyst. This tumor may behave in a locally aggressive manner and be resistant to pelvic radiation or single-agent chemotherapy of cis-platinum. The current experience of adjuvant treatment after comprehensive staging and cytoreductive surgery reported in the world literature is limited, and the optimal management of the malignancy remains unclear.

A study of client-focused case management and consumer advocacy: the Community and Consumer Service Project

OBJECTIVE

The study investigated the provision of client-focused services to community-based clients with schizophrenia and bipolar disorder. It hypothesised that the delivery of more client-focused services would improve client outcome in terms of functioning, disability and satisfaction with services. Client-focused services were developed using an empowerment model of case management and by the addition of consumer advocates.

METHOD

Clients referred for case management were randomly allocated to one of three groups: standard case management (n = 35), client-focused case management (n = 39), or client-focused case management plus consumer advocacy (n = 45). Measures of functioning, disability, quality of life, burden of care and service satisfaction were measured at baseline and 12 months. Outcome data were collected concerning number and duration of hospital readmission, crisis intervention and compliance with treatment and services.

RESULTS

While there were no differences between the groups on quantitative measures of functioning, disability, quality of life, service satisfaction and burden of care, there were significant between-group differences on qualitative measures of satisfaction with services.

CONCLUSIONS

Several methodological difficulties hampered interpretation of the findings. Although clients did not differ on outcome measures of functioning and disability, the group receiving client-focused case management reported greater satisfaction with service delivery.

Development of neutralising human recombinant antibodies to pertussis toxin

A phage antibody display library of single chain Fv (scFv) was derived from the peripheral blood of two patients recently recovered from pertussis infection. Ten scFv, differentiated by DNA fingerprinting, were isolated by panning the library against pertussis toxin. One scFv (type 1) accounted for 33% of clones after panning. Six of the panned scFv bound to pertussis toxin. The ability of the scFv to neutralise pertussis toxin was assessed using the Chinese hamster ovary cell assay. The predominant scFv (type 1) and two others (types IV and VIII) were able to neutralise the pertussis toxin.

Cervical sarcoma botryoides. A case report

BACKGROUND

Sarcoma botryoides is a rare gynecologic malignancy. Reported treatment protocols range from localized resection of the tumor to radical surgery and adjuvant chemotherapy. Recently, limited excisional surgery combined with chemotherapy has contributed to excellent survival rates and preserved bladder and rectal function.

CASE

We report a case of cervical sarcoma botryoides with minimal invasion. The patient had primary surgical treatment with complete resection of the tumor without adjuvant chemotherapy. Four months after surgery she presented with extensive metastatic retroperitoneal disease and died two weeks later.

CONCLUSION

The clinical course of this patient suggests that complete surgical resection in cases of localized disease is not adequate therapy for sarcoma botryoides. Adjuvant chemotherapy should always be used, even at a very early stage.

When not to syringe an ear

This article reviews the potential hazards of ear syringing and the Accident Compensation Corporation Medical Misadventure Unit's experience of alleged iatrogenic injury over a 17-month period. Syringing claims account for about 25% of the total claims received by the ACC ENT Medical Misadventure Committee. Forty-seven claims were accepted as either mishap or error, and 63 claims were declined. Perforation of the drum was by far the commonest injury resulting in significant disability. Severe iatrogenic otitis externa accounted for most of the remainder. Practice nurses had syringed the ears of approximately two-thirds of the claimants with significant disability. The contraindications to ear syringing are listed and discussed. The correct technique, with a few "do and don't" pointers, is briefly reviewed. Management of the unintentional injury is discussed.

Is HIV infection a risk factor for advanced cervical cancer?

OBJECTIVES

To compare HIV-infected and HIV-negative women with invasive cervical cancer with respect to predictors of advanced disease.

METHODS

A retrospective analysis of 28 HIV-positive and 132 HIV-negative women with invasive cervical carcinoma was conducted and the two groups were compared with regard to stage of disease, demographic and behavioral variables, and risk factors for advanced disease.

RESULTS

Overall, HIV-infected women were more likely to have advanced disease, because 78% of HIV-positive women had Stage II to IV compared with 55% of HIV-negative women (odds ratio [OR] = 3.1; p = .03). Substance abuse was strongly associated with HIV infection, as were high-risk sexual variables. Although HIV infection was associated with a threefold increase in advance stage cervical cancer in a univariate analysis, only symptom duration and lack of a recent Papanicolaou smear were significant predictors of advanced disease in a multiple logistic regression analysis.

CONCLUSIONS

The major predictors of advanced cervical cancer are similar in HIV-positive and HIV-negative women, although the reasons for these predictors may be very different. It is likely that a large proportion of HIV-positive patients with cervical cancer acquire HIV infection after initiation of the neoplastic process.

Labor ward workload waxes and wanes with the lunar cycle, myth or reality?

Objective: To test the validity of the statement "We are busy because it is getting close to the full moon" often heard on labor ward, by analysis of birth statistics in relation to lunar cycles.Method: Data for births from spontaneous onset labors for 12 lunar cycles from January 1 to December 31, 1994 was analyzed. Births resulting from induced labors were excluded. Birthrate for each day of the lunar cycle from new moon to full moon (ascending lunar phase) and from full moon to new moon (descending lunar phase) were analyzed using Pearson correlation coefficient. Birthrate at full moon was compared to that at new moon and that at mid ascending lunar phase was compared with that at mid descending lunar phase using t test.Results: There were 3706 spontaneous births during the study period. The average daily birthrate was 10.58 with standard deviation (SD) of 1.27. There was no statistically significant difference in the daily birthrate between the ascending and the descending lunar phases, r = -0.21. Statistical analysis showed no significant difference in the number of births at full moon as compared to that at new moon, P =.44. No difference was found on comparison of number of births during the mid ascending phase to that at the mid descending lunar phase, P =.84.Conclusion: Scientific analysis of data does not support the belief that the number of births increases as the full moon approaches, therefore it is a myth not reality.

Crohn's disease presenting with Fournier's gangrene and enterovesical fistula

Our purpose is to make a case for early operative intervention. A 37-year-old man presented with a large periurethral abscess and Fournier's gangrene. During the ensuing evaluation and treatment, he was found to have previously undiagnosed Crohn's disease with a complex enterovesical fistula. This case stands in contrast to other reports that downplay the morbidity of enterovesical fistula associated with Crohn's disease and advise medical management until gastrointestinal complications require operative intervention.

The efficacy of local anaesthetics administered by general dental practitioners

AIM

To obtain empirical evidence for the efficacy of local anaesthesia in dentistry.

DESIGN

Retrospective analysis of serial administrations of local anaesthesia.

METHODS

Dentist and patient evaluations of the success of differing techniques (infiltration and block) of anaesthesia in a variety of general practice procedures. Results were analysed for correlation between dentist and patient using a 5-point scale.

RESULTS

Complete data were analysed for 331 administrations. In the hands of experienced dentists over 93% of operations were assessed by both dentist and patient as comfortable or completely comfortable. Dentists were generally able to judge patient comfort (P < 0.001). Administrations requiring repeat injections were less comfortable. Dentists judged infiltration administrations more comfortable than block administrations (P < 0.001), but patient judgements of comfort failed to distinguish between differing techniques at the P < 0.05 level.

CONCLUSIONS

Some variations in success rate exist between dentists the most dental procedures under local anaesthetic in general practice were assessed as being comfortable or better by both dentists and patients.

Cardiovascular collapse after femoral prosthesis surgery for acute hip fracture

PURPOSE

Prosthetic revision of hip fractures may result in embolization of tissue products leading to death. In this report, from cases reported to the Anaesthesia Advisory Committee to the Chief Coroner of Ontario, emphasis is placed on the immediate resuscitative procedures which may offset a fatal outcome.

CLINICAL FEATURES

Two elderly patients are reported in whom hip fractures necessitated primary prosthetic hip repair. The first patient, with a history of limited cardiac reserve and syncope, suffered a subcapital hip fracture. Under general anaesthesia, a Moore's prosthesis was inserted. The anaesthetic period remained relatively stable until surgical reaming of the femoral canal. Bradycardia, hypotension and cyanosis developed and quickly proceeded to a fatal cardiac arrest. Autopsy demonstrated diffuse pulmonary embolism of fat and thrombus. The second patient suffered a fracture around the stem of a previously inserted femoral prosthesis. Under general anaesthesia, a new cemented hip prosthesis was inserted, following which hypotension occurred. This was supported with small doses of ephedrine, ventilation was controlled with oxygen and the procedure was quickly terminated. Despite addition of a dopamine infusion, cardiac arrest and death followed. Autopsy disclosed massive fat and bone marrow embolization.

CONCLUSION

The combination of hip fracture, activated clotting factors and borderline cardiopulmonary function presents a risk of death from embolization of tissue products released during the placement of a cemented hip prosthesis. While the outcome of this catastrophe is generally poor, all practitioners should be prepared to immediately institute resuscitative procedures to manage the accompanying cardiovascular collapse.

Cervical cancer as an AIDS-defining illness

OBJECTIVE

To evaluate the importance of cervical cancer in the spectrum of human immunodeficiency virus (HIV)-related diseases at a single high-risk institution and to compare disease characteristics in HIV-infected women with cervical cancer and those with other AIDS-related malignancies.

METHODS

We retrospectively reviewed data on cervical cancer and AIDS in women registered through the New York City Department of Health and institutional tumor registries from 1987 through 1995.

RESULTS

During the study period, cervical cancer was diagnosed in 28 HIV-positive women. In 26, cervical cancer was the initial AIDS-defining illness, representing 4% (26 of 725) of the subjects, and it was the sixth most common initial AIDS-defining illness in women. Cervical cancer was the most common AIDS-related malignancy among women, representing 55% of the cases, followed by lymphoma (29%) and Kaposi sarcoma (16%). In 71% of the women with cervical cancer, HIV infection was diagnosed at the time of cancer presentation by routine testing, whereas in women with other malignancies, HIV diagnosis preceded cancer diagnosis (70%) by a mean of 2.7 years. Patients with other malignancies had greater immunosuppression (mean CD4 count 153/microL) than those with cervical cancer (mean CD4 count 312/microL). The recurrence rate for women with cervical cancer was 88%. Although the interval from cancer diagnosis to death was similar in all three groups (9.1-12.4 months), cancer was the cause of death in 95% of HIV-infected women with cervical cancer, compared with 60% of those with other AIDS-related malignancies.

CONCLUSION

In urban populations at increased risk for both diseases, cervical cancer is an important AIDS-defining illness and may be the most common AIDS-related malignancy in women.

Over-expression of Saccharomyces cerevisiae hsp90 enhances the virulence of this yeast in mice

Saccharomyces cerevisiae, a yeast of low pathogenic potential, is a rare but well-documented cause of invasive infections in humans. The yeast Candida albicans is a much commoner cause of significant and life-threatening infections. In such infections the heat shock protein hsp90 is an immunodominant antigen associated with protective humoral immunity. In this study it was shown that over-expression of S. cerevisiae hsp90, the amino acid sequence of which shows 84% identity to C. albicans hsp90, significantly increased the virulence of a laboratory strain of S. cerevisiae in mice, both in terms of colony counts in the kidney, liver, and spleen, and in terms of mortality. This is the first direct evidence that hsp90 is a virulence factor.

Antibodies against Candida: potential therapeutics?

For many years, there has been controversy over the role of antibodies in immunity to Candida, but recently specific antibodies to mannoproteins and hsp90 have been shown to be protective against murine candidiasis. Combined with technical advances in antibody engineering, this raises the possibility of harnessing such antibodies into a new range of therapeutics.

Epitope mapping the Fim2 and Fim3 proteins of Bordetella pertussis with sera from patients infected with or vaccinated against whooping cough

Antibody-binding epitopes on the Fim2 and Fim3 proteins of Bordetella pertussis, which have been associated with the induction of protective antibody, were located using sera from 12 patients with whooping cough and 4 vaccinated children. Fifteen epitopes were identified on both Fim2 and Fim3. In each case 9 were recognised by serum antibody from 11 or more infected patients. Epitopes associated with the highest IgG activity were not the same as those associated with the highest IgA activity. None of the vaccinated patients had detectable IgA. Most epitopes showed little or no evidence of serotype-specific responses, suggesting this is largely directed towards conformational epitopes. The reactivity of all but two epitopes was confirmed in an ELISA with patients' sera in which epitopes were re-synthesised as free soluble peptides. The short linear epitopes described may therefore be useful in the development of serodiagnostic assays but are unlikely vaccine candidates.

Analysis of thiol-containing compounds in biological samples by capillary zone electrophoresis

A new method for the determination of reduced and oxidized glutathione by using capillary zone electrophoresis was developed and compared with the N-(1-pyrenyl)maleimide high-performance liquid chromotography method. The tissue samples were obtained from C57BL/6 mice and homogenized in deionized water. The detection wavelength was set at 214 nm. A 50-cm effective length x 75 microns i.d. uncoated fused silica capillary with a 10 mM phosphate buffer at pH 7.5 was used for the experiment. Samples were introduced by pressure injection for 5s. The voltage for separation was at 20 kV. Between runs, the capillary was regularly washed with 0.1 N NaOH and deionized water, followed by reconditioning with running buffer. The present method was shown to be reproducible and is convenient in that a derivatization step is not required. The method has been used to measure glutathione levels in biological samples and the results show good agreement with those obtained by high-performance liquid chromotography.

Protective effect of vitamin E on lymphocyte growth capacity during incubation in vitro

Vitamin E, an essential lipid-soluble micronutrient, plays an important role in the immune system and serves as an immunostimulant in geriatric subjects. Using an in vitro incubation to simulate aging processes, we find that vitamin E mitigates loss of growth capacity in lymphocytes. Vitamin E presence during in vitro incubation did not affect significantly the level of peroxidation, the effects of exogenous IL-2, PGE2, or indomethacin, nor levels of IL-2 production. Thus, the preservative effect on lymphocyte growth by vitamin E is not due primarily to its antioxidant function or to interleukin-2 or prostaglandin effects. The decreased growth capacity generated by in vitro incubation is accompanied by a variety of cellular alterations, including decreased CD5 surface antigen, enhanced suppression by adherent cells, and impaired communication between lymphocytes and adherent cells. The decrease in CD5 surface antigen correlates inversely with the cell density required for maximal cell proliferation, and the diminished CD5 levels were unaltered by vitamin E presence during the aging process. In contrast, protection of T-cell proliferative capacity by vitamin E in vitro correlates with diminished suppression by adherent cells and normalized interaction between lymphocytes and adherent cells.

Human lymphocytes incubated in vitro share multiple characteristics with geriatric-derived lymphocytes: a potential in vitro model for aging?

Aging involves a complicated set of parallel reactions that result in multiple cellular and organismic changes and may eventuate in chronic illness. In the immune system, several alterations that correlate with age have been established. In the present study, we report the results of incubating lymphocytes in vitro in whole blood and, employing measures known to be age-dependent, compare these cells 'aged' in vitro with cells from geriatric patients aged in vivo. Cells from blood aged in vivo and incubated in vitro share a number of common characteristics that include decreased growth capacity, shifted growth patterns, increased suppression by adherent cells, decrease in CD5 surface antigen, similar responses to addition of exogenous IL-1, IL-2, PGE2, or indomethacin, and similar production of PGE2. Differences found between in vivo aging and in vitro incubation are IL-2 plasma levels and IL-2 production by activated cells monitored in conditioned minimal medium. Based on these observations, this in vitro system provides a simple method to generate cells that exhibit a very significant subset, but not all, of the characteristics associated with in vivo aging in lymphocytes.

Short stature in homozygous beta-thalassaemia is due to disproportionate truncal shortening

BACKGROUND AND OBJECTIVE

Growth failure in homozygous beta-thalassaemia has been recognized for many years, and has persisted despite major treatment advances. In this cross-sectional study, sitting and standing height were measured to determine whether growth failure was disproportionate.

DESIGN

Patient data were analysed in three age groups, 2-10 years, 11-18 years and 19 and over. Sitting height and subischial leg length were also determined in a cohort of parents (n = 19) and normal Greek adolescents (n = 32).

PATIENTS AND MEASUREMENTS

Of the known 156 patients with homozygous beta-thalassaemia in the State of Victoria, 154 (98.7%) attend our institution. Sitting and standing heights were measured, using Harpenden stadiometers, in 57 of 60 (95%) patients aged 2-18 years and in a random selection of 51 of 89 patients aged 19 and over (57%). Measurements are expressed as mean +/- SDS. Other data analysed included serum concentrations of ferritin, zinc, copper, FSH, LH, oestradiol and testosterone, according to standard laboratory assays, together with pubertal status and bone age in patients aged less than 19 years.

RESULTS

Standing height standard deviation scores in the 2-10 age group were -0.687 +/- 0.861 (n = 9), in the 11-18 age group were -1.838 +/- 1.413 (n = 48) and in the age group 19 and over were -1.175 +/- 1.126. In individuals aged 2-10 years, sitting height standard deviation scores (SDS) were -1.56 +/- 1.02, in individuals 11-18 years were -3.76 +/- 1.51 (n = 48), and in individuals 19 years and over were -2.77 +/- 1.20 (n = 51), compared with subischial leg length SDS which were, in individuals aged 2-10 years 0.214 +/- 0.91; in 11-18 years, -0.063 +/- 1.347, and in individuals 19 and over, 0.37 +/- 1.18. These data show that the reduction in standing height was the result of truncal shortening. Mean sitting height SDS was significantly lower in children with homozygous beta-thalassaemia, compared with their parents (P < 0.001), and in a subgroup of Greek adolescents with homozygous beta-thalassaemia compared with age and sex matched normal Greek adolescents (P < 0.001). No correlation was found between truncal shortening and other clinical and biochemical variables measured.

CONCLUSIONS

Short stature in our patients with homozygous beta-thalassaemia is due to disproportionate truncal shortening. The aetiology of truncal shortening in this patient group is likely to be multifactorial, although hypogonadism and chelation therapy may be contributory factors.

Preliminary assessment of a human recombinant antibody fragment to hsp90 in murine invasive candidiasis

Seroconversion to hsp90 is associated with recovery from systemic candidiasis in humans, and a murine monoclonal antibody to this hsp90 antigen (LKVIRK epitope) was protective in mice. A human recombinant antibody to the same epitope was assessed in acute and chronic models of murine invasive candidiasis. Lethal intravenous challenge with fluconazole-susceptible (strain 4) or fluconazole-resistant (strain 019) Candida albicans, followed 2 h later by a single dose of recombinant antibody, was associated with a statistically significant drop in mortality of > or = 40% (two experiments in BALB/c mice given strain 4; one experiment in CD-1 mice given strain 019) or 23% (BALB/c mice, strain 019). In mice sublethally infected with strain 4, treatment with recombinant antibody was associated with improved renal clearance of infection. Antibody-mediated protection may involve neutralization of the protein-binding properties of circulating candidal hsp90, since LKVIRK strongly bound dexamethasone in vitro.

Quantitative two-dimensional echocardiographic assessment of regional wall motion during transient ischemia and reperfusion in the rat

Nonlethal myocardial ischemia produces profound and long-lasting effects on regional ventricular function and metabolism (myocardial stunning) and protects against myocardial infarction from subsequent prolonged ischemia (ischemic preconditioning). Two-dimensional echocardiography (2DE) is an essential tool for quantitative analysis of regional and global left ventricular (LV) function during myocardial ischemia and reperfusion and the study of these phenomena. However, the inability to perform 2DE in the open-chest rat heart has seriously limited the use of this model. To investigate the effect of transient coronary occlusion on segmental wall motion and LV geometry, we employed a 20 MHz intravascular ultrasound catheter placed on the epicardial surface of the rat heart (n = 15) to yield 2DE images suitable for quantitative analysis. Three 2-minute left coronary occlusions were made, separated by 5 minutes of reperfusion, with imaging during occlusion and at 5 and 60 minutes of reperfusion. Ischemic and nonischemic wall thicknesses, LV cross-sectional area, estimated LV volume, and the fractional changes of these parameters were measured. In eight animals these values were also compared with necropsy measurements of wall thickness, LV cross-sectional area, and volume. LV and right ventricular structures were well visualized in short-axis cross-sectional images in all animals, and images suitable for quantitative analysis were obtained in 92% of the periods. Coronary occlusion caused immediate, marked LV cavitary expansion, which rapidly returned to normal by 5 minutes of reperfusion. Active systolic thickening of the anterior wall at baseline (47% +/- 3%) became passive thinning during occlusion (-6% +/- 2%) and recovered partially, to 30% +/- 3% at 5 minutes of reperfusion and 42% +/- 4% at 60 minutes (p < 0.0005 at 5 minutes of reperfusion vs baseline; p not significant at 60 minutes). Recovery of thickening after 5 minutes of reperfusion was not different after the first versus third occlusion (23% +/- 4% vs 30% +/- 3%; p = 0.19). Measurements made by 2DE correlated well with those made by necropsy, although wall thickness was slightly thicker by 2DE. We conclude that epicardial echocardiography with an intravascular ultrasound catheter provides quantifiable 2DE images in this model and yields accurate information on segmental wall thickening and ventricular geometry not available by other techniques. Left coronary occlusion in the rat is associated with marked global and segmental LV expansion, which rapidly reverses with reperfusion. Postischemic regional wall motion abnormalities are present after coronary occlusion as brief as 2 minutes and can be measured accurately. The effect of multiple brief occlusions is not cumulative.(ABSTRACT TRUNCATED AT 400 WORDS)

Glycerol-3-phosphate dehydrogenase activity in human lymphocytes: effects of insulin, obesity and weight loss

Insulin exposure stimulates an increase in glycerol-3-phosphate dehydrogenase (G3PDH) activity in isolated human lymphocytes that correlates to an increase in G3PDH mRNA and requires new protein synthesis. Synthetic diacylglycerol or phorbol ester can mimic the effect of insulin on G3PDH activity, suggesting that protein kinase C may be involved in regulation of G3PDH levels. In addition, lithium chloride, an inositol phosphate phosphatase inhibitor, and calcium uptake inhibitors can abolish insulin stimulation of G3PDH activity. For obese subjects in whom insulin resistance in vitro can be demonstrated, the extent of insulin stimulation of G3PDH activity is decreased compared to normal weight individuals, and treatment by a very low calorie diet restores insulin stimulation of G3PDH activity. Thus, insulin stimulation of G3PDH activity is dependent upon the metabolic state of the subject from whom the cells are obtained.

Effect of enalapril in dogs with pacing-induced heart failure

A repeated-measures study was conducted on 5 dogs to clinically, radiographically, and echocardiographically characterize the actions of the angiotensin-converting enzyme inhibitor, enalapril, before and after development of experimentally induced heart failure. Heart failure was artificially induced, using a surgically implanted programmable ventricular pacemaker, which stimulated the heart at a rate of 245 beats/min until a low-output cardiomyopathic state developed. This condition was then stabilized by decreasing the pacing rate to 190 beats/min. Pacing-induced heart failure was successfully induced in a mean +/- SD 4.2 +/- 1.95 weeks. The condition closely resembled the clinical, radiographic, and echocardiographic features of naturally acquired idiopathic dilated cardiomyopathy in dogs. Enalapril was well tolerated by dogs, and clinical adverse reactions did not develop. Results of echocardiographic studies indicated that enalapril treatment during the control period resulted in a significant (P < 0.05) increase in velocity of circumferential fiber shortening and a significant (P < 0.05) decrease in left ventricular ejection time. Therapeutic responses to enalapril were evident after development of heart failure. These included reduced severity of clinical signs of disease, evidence of decreased radiographically determined cardiac size (2 of 5 dogs), radiographic evidence of a reduction in pulmonary edema and congestion (4 of 5 dogs), significant (P < 0.05) reductions in left atrial and ventricular chamber dimensions (left atrial dimension, diastolic left ventricular internal dimension as determined echocardiographically), and improvement in some echocardiographic indices of left ventricular performance (velocity of circumferential fiber shortening and left ventricular ejection time).