Hypertrophic cardiomyopathy. Why is it often overlooked in elderly patients?

The lack of awareness that hypertrophic cardiomyopathy is indeed seen in older patients is widespread. The resulting low index of suspicion, coupled with the fact that the clinical presentation of this condition closely resembles the presentations of several common disorders of the elderly, can lead to misdiagnosis and inappropriate and possibly harmful treatment. When an elderly patient presents with dyspnea, angina, or syncope, the presence of a systolic murmur that changes in intensity with appropriate diagnostic maneuvers should prompt consideration of hypertrophic cardiomyopathy, which can be easily verified (or excluded) by echocardiography. This approach minimizes diagnostic and therapeutic errors.

The genetics of rheumatic fever: relationship to streptococcal infection and autoimmune disease

A large body of evidence suggests that patients with rheumatic fever immunologically respond abnormally both at a humoral and cellular level to streptococcal antigens cross-reactive with mammalian tissues. Implicit in this concept is that this abnormal immune response is genetically programmed. Using a monoclonal antibody called D8/17, a B cell marker has now been identified in 90-100% of all patients with rheumatic fever tested in 5 different geographical and ethnic populations. This trait appears to be inherited in an autosomal recessive fashion. This recognition of a B cell marker unique to individuals with rheumatic fever has important public health implications with respect to identification of individuals susceptible to rheumatic fever, possible prevention of disease and the recognition of prime candidates for future streptococcal vaccines.

Patent ductus arteriosus in a Holstein calf: A two-dimensional and Doppler echocardiographic study of the ductus arteriosus and validation

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Pre-pubic vasectomy--a new approach

Four hundred and fifty cases were operated for vasectomy by pre-pubic approach. The relative fixity of vas at this place made this approach easier than conventional scrotal approach. Mean healing duration was 6.06 days. This approach leaves the scrotum free, needs no scrotal support and scrotum is not involved in hematoma and inflammatory complications. Thus the pre-pubic approach for vasectomy provides a superior and beneficial alternative to conventional scrotal approach.

A new clinical test in gastroduodenal perforation

Forty-nine cases of gastroduodenal perforation were subjected to new air insufflation test. The clinical and radiological criteria of air insufflation test were applied to every patient of this study. Forty-seven cases (95.9%) were positive to the new test whereas 2 negative cases turned out to be old sealing perforation. The new test is highly useful in preoperative detection of site of perforation in perforative peritonitis.

Fine-needle aspiration cytology of abdominal masses

An investigation of the role of blind fine-needle aspiration cytology (FNAC) in the assessment of palpable abdominal masses was carried out on 196 patients: 124 hepatic, 30 retroperitoneal, and 42 other masses. All of the smears were stained either by Papanicolaou stain or by hematoxylin and eosin stain. The results of FNAC were confirmed by further investigations in all cases. FNAC correctly diagnosed 166 (84.6%) cases. Twenty (10.2%) reports were false negative, and 10 (5.1%) smears were unsatisfactory for any diagnosis. Of 124 hepatic masses, the correct diagnosis was obtained in 106 (85.4%), false-negative reports in 14 (11.2%), and unsatisfactory smears in 4 (3.2%). There were no false-positive reports. For all the lesions, the sensitivity of FNAC was 87.8%; specificity, 100%; positive predictive value, 100%; and negative predictive value, 52.4%. Five (2.5%) patients had considerable pain after the procedure.

The revised ARPANET routing metric

The ARPANET routing metric was revised in July 1987, resulting in substantial performance improvements, especially in terms of user delay and effective network capacity. These revisions only affect the individual link costs (or metrics) on which the PSN (packet switching node) bases its routing decisions. They do not affect the SPF (“shortest path first”) algorithm employed to compute routes (installed in May 1979). The previous link metric was packet delay averaged over a ten second interval, which performed effectively under light-to-moderate traffic conditions. However, in heavily loaded networks it led to routing instabilities and wasted link and processor bandwidth.

The revised metric constitutes a move away from the strict delay metric: it acts similar to a delay-based metric under lightly loads and to a capacity-based metric under heavy loads. It will not always result in shortest-delay paths. Since the delay metric produced shortest-delay paths only under conditions of light loading, the revised metric involves giving up the guarantee of shortest-delay paths under light traffic conditions for the sake of vastly improved performance under heavy traffic conditions.

Primary closure of lactational breast abscess

The effect of incision drainage and primary closure on 50 cases (age ranging from 16 to 35 years) of lactational breast abscess was studied. The mean healing time was 7.12 days. Failure rate was 6%. It is concluded that primary closure technique is safe, economical and highly beneficial in comparison to conventional open drainage pack dressing method. A close and watchful postoperative care along with other factors is mandatory for the success.

Hypertrophic cardiomyopathy in the elderly. A frequently misdiagnosed disease

In 20 elderly patients (mean age, 76 years; range, 70 to 86 years), hypertrophic cardiomyopathy was diagnosed echocardiographically. Although the disease was moderate to severe in all patients, the diagnosis was not suspected in 19 patients prior to echocardiography. Inappropriate therapy consisting of potentially harmful drugs, such as digitalis, nitrates, and diuretics, was commonly used, often for unclear indications. Since echocardiography can easily and accurately diagnose hypertrophic cardiomyopathy, an increased awareness of its occurrence in the elderly and use of echocardiography would reduce diagnostic and therapeutic errors.

Mitomycin C extravasation ulcers

In a four-year period, eight patients with mitomycin C extravasation ulcers were encountered. Mitomycin C extravasation produces a painful indolent ulcer that does not have any tendency to heal. If extravasation of the drug is recognized, infusion should be stopped immediately, and the site of infusion should be changed. The ulcers should be excised, and primary closure is recommended; if it is not possible then the defect is covered by a partial thickness skin graft.

Immunological status of trophoblastic neoplasia

Six cases of choriocarcinoma, 17 of vesicular mole, 20 normal pregnant females in the first trimester of pregnancy, and 20 normal nonpregnant women wih previous normal obstetrical history were evaluated quantitatively for cell-mediated immunity by response to 2:4 dinitrocholorobenzene and recall antigens. Serum immunoglobulins were estimated in all cases. Suppression of cell-mediated immunity was marked in choriocarcinoma as compared to vesicular mole. Serum IgG levels were significantly diminished in cases of vesicular mole, indicating diminished humoral immunity. Follow-up after 3 months of treatment with surgery and chemotherapy resulted in marked improvement of cell-mediated immunity.

Mitral valve prolapse and cerebrovascular accidents in the young

The incidence of stroke in the young is reported to be high in India. The role of the mitral valve prolapse (MVP) syndrome in these patients is not clear. A prospective study over a period of 1 year was carried out in order to evaluate the role of MVP in cases of stroke occurring in patients below the age of 40 years. Of the 38 cases of stroke in the young seen during this period, well-recognised risk factors of stroke could be detected in 17. MVP confirmed by M-mode echocardiography was seen in 13% of all stroke patients and in 23.8% of those in which there were no other risk factors. The incidence of MVP was much higher if only the clinical criteria for diagnosis were used. We believe that MVP is a significant risk factor in younger stroke patients, and, in such cases, merits investigation. The probable pathogenic mechanisms and therapeutic implications are discussed.

Red blood cell survival in patients with ventricular septal defect and patent ductus arteriosus

Hemolysis of red blood cells (RBC) in stenotic or regurgitant cardiac valvular lesions has been felt to be due to mechanical trauma and shearing stress caused by turbulence of blood. RBC are also under a shearing stress from turbulence in high-pressure shunts, such as ventricular septal defect (VSD) and patent ductus arteriosus (PDA). The RBC survival time was measured in five patients with VSD and in 11 patients with PDA to determine if there was hemolysis of RBC. Six children without cardiac disease were also studied to obtain the control values for RBC survival times in th laboratory. Two patients with PDA were restudied one year postoperatively. Additional parameters studied were hemoglobin, packed cell volume, reticulocyte cell count, peripheral smear, and urinary hemosiderin. The hemoglobin values and the packed cell volumes were comparable in the two groups. The reticulocyte cell count was normal in all. Urinary hemosiderin was negative in all and the peripheral smear did not reveal abnormal red cell morphology. Mean red cell survival half-life in the two groups was identical. The red cell survival was abnormally low in two patients of PDA. Since one of these two patients had persistently low RBC survival postoperatively, the authors believe that the low red cell survival in this patient was unrelated to the presence of PDA. Based on findings in the small number of cases, the authors conclude that left to right shunt through a VSD or PDA is probably not associated with significant red blood cell destruction.