An epidemiologic study of index and family infectious mononucleosis and adult Hodgkin's disease (HD): evidence for a specific association with EBV+ve HD in young adults.

Infectious mononucleosis (IM) is an established risk factor for Hodgkin's disease (HD). A substantial minority (33%) of cases of HD have Epstein-Barr virus (EBV) DNA within the malignant cells (are EBV+ve). It is unclear whether risk after IM applies specifically to EBV+ve HD. We report the results of a population-based case-control study of HD in adults (n = 408 cases of classical HD, 513 controls) aged 16-74 years; the case series included 113 EBV+ve and 243 EBV+ve HD. Analyses compared total HD, EBV+ve HD and EBV-ve HD with the controls and EBV+ve HD with EBV-ve HD cases using, mainly, logistic regression. Regression analyses were adjusted for gender, age-group and socioeconomic status, and were performed for the whole age range and separately for young (< 35 years) and old adults (> or = 35 years); formal tests of effect modification by age were included. For the young adults, reported IM in index or relative was strongly and significantly associated with EBV+ve HD when compared to controls (odds ratio [OR] = 2.94, 95% confidence interval [CI]: 1.08-7.98 and OR = 5.22, 95% CI: 2.15-12.68, respectively). These results may be interpreted as indications that late first exposure to EBV increases risk of HD, especially in young adults; this applies primarily to EBV+ve HD.

Asymptomatic left main coronary artery disease and silent myocardial ischemia.

Gathering data on the prognosis, detection, and natural history of asymptomatic left main coronary artery disease with silent myocardial ischemia is difficult. Epidemiologic studies of unexpected death and postmortem studies on silent myocardial infarction suggest this entity to be common. We reviewed 89 consecutive patients with left main coronary artery disease (LMD), defined as 50% or greater reduction of luminal diameter. Of this group, 10 patients (11%) were asymptomatic (ALMD) and 79 patients (88%) were symptomatic (SLMD). All 10 ALMD patients were men, with a mean age of 53 years (range 40 to 65). Treadmill tests (TMT) were performed for: ECG abnormalities six; pre-jogging evaluation two; risk factor evaluation two. The TMT within 9 minutes showed 2 mm or greater ST depression in seven (70%) and 1 to 2 mm in three (30%). Similar TMT results were obtained in the SLMD group, although two patients had negative responses. The degree of stenosis of the left main coronary artery and the frequency of three-vessel disease were similar in both groups. The ejection fraction (EF) and contractile pattern of the left ventricle (LV) were normal in all 10 ALMD patients, but the left ventricular end-diastolic pressure (LVEDP) was abnormal in three (70%). In the SLMD group, 51 (64%) had an abnormal ejection fraction, 50 (65%) had wall motion abnormalities, and 25 (32%) had an abnormal LVEDP.

Cardiac abnormalities in mixed connective tissue disease.

Sixteen patients with mixed connective tissue disease (MCTD) were studied using noninvasive cardiovascular techniques. Cardiovascular abnormalities including pericarditis, asymmetric septal hypertrophy, and LV dilatation were found in 38 percent of the study group. Borderline ECG and echocardiographic abnormalities were present in 31 percent of the study group, and the remaining 31 percent were normal by all study techniques. MCTD patients have a high prevalence of cardiovascular abnormalities when studied noninvasively. The most common clinical abnormality is a steroid-responsive pericarditis, present in 25 percent of our series.

Propranolol medication among coronary patients: relationship to type A behavior and cardiovascular response.

The present correlational study compared behavioral and psychophysiological characteristics of coronary patients who were either medicated or not medicated with the beta-adrenergic blocking drug propranolol. Eighty-eight patients were given a structured Type A interview (SI) and a history quiz while heart rate and blood pressure were monitored. Data were analyzed controlling for age, sex, extent of coronary artery disease, and history of angina. Results indicated that patients taking propranolol (n = 65) were significantly lower in intensity of Type A behavior than patients not taking propranolol (n = 23). No effects were obtained for patients medicated or not medicated with diuretics, nitrates, or other CNS active drugs. Propranolol patients also showed lesser heart rate and rate-pressure product responses to the interview, but did not differ in blood pressure responses. Components of Type A which were lower in propranolol patients included speech stylistics (loud/explosive, rapid/accelerated, potential for hostility). Content of responses to the SI and scores on the Jenkins Activity Survey did not differ between the groups. An explanation for these results is offered in terms of the effects of propranolol on peripheral sympathetic responses, and evidence for a physiological substrate for Type A behavior. A conceptualization of the Type A pattern in terms of cognitive and physiological components is advanced, and implications for clinical intervention are discussed.

Type A behavior and coronary artery bypass surgery: intraoperative blood pressure and perioperative complications.

Previous research has suggested that Type A, compared to Type B patients undergoing coronary artery bypass surgery evidence greater intraoperative increases over hospital admission systolic blood pressure, even though patients are under general anesthesia. The present study sought to examine whether such blood pressure increases are accounted for by elevations occurring entirely during surgery (with conscious mediation minimized), or by increases occurring prior to surgery. A second purpose of the study was to examine the relationship between Type A behavior and complications occurring during and after surgery. Twenty-seven male patients given a structured interview to measure Type A behavior in advance of surgery comprised the present sample. Results indicated that interview Type A intensity was reliably related to magnitude of systolic, but not diastolic blood pressure increases during, but not prior to surgery. The 12 patients with complications (largely arrhythmias), were reliably higher in rated intensity of Type A behavior (p less than 0.01) than those without complications (n = 14). None of the Type B or Type X patients showed evidence of complications during or after surgery. Results of this study support a body of data linking Type A behavior to cardiovascular reactivity and clinical complications of coronary disease. Since this reactivity is evident under general anesthesia, these data further suggest that conscious mediation may not always be necessary in order to elicit these responses.

Coronary atherosclerosis in mitral stenosis.

Eighty-two patients with mitral stenosis underwent cardiac catheterization with coronary angiography. Twenty-one patients (26 percent) had coronary artery disease. Characteristics of the mitral valve area, cardiac output, pulmonary artery pressure, pulmonary vascular resistance, left ventricular end-diastolic pressure, left ventricular ejection fraction, and atypical chest pain did not correlate with findings of angina pectoris or of coronary artery disease; however, there was correlation with sex, age, and angina. Coronary artery disease occurred only after the age of 40 years and was more frequent in males with angina. Coronary artery disease could not be ruled out in patients with mitral stenosis, especially those over age 40, without coronary arteriography.

Dipyridamole-aspirin as thromboembolic prophylaxis in patients with aortic valve prosthesis. Prospective study with the Model 2320 Starr-Edwards prosthesis.

In a prospective study, the efficacy of a dipyridamole-aspirin regimen in prevention of thromboembolism was evaluated in 50 patients having isolated aortic valve replacement with the Model 2320 Starr-Edwards prosthesis. These operations were performed between February, 1972, and October, 1974. In 1,380 patient-months of follow-up, there was a 20% incidence of thromboembolism with a rate of 8.7/100 patient-years and a 19% probability of an embolic episode occurring by 3 years. Seven patients had transient episodes, two had permanent neurologic residua, and one patient died. Comparison is made to a similar group of patients having solitary aortic valve replacement but receiving no medication, studied by Starr and associates. There was no statistical difference in the incidence of thromboembolism between the two groups. In November, 1975, all patients were converted to a regimen of warfarin therapy. Since conversion to anticoagulation, there have been two thromboembolic episodes in 2,132 patient-months of follow-up for a rate of 1.1/100 patient-years. We conclude that the use of antiplatelet therapy in the form of dipyridamole-aspirin is inadequate for routine thromboembolic prophylaxis following SE 2320 aortic valve replacement.

ST-segment elevation with elective DC cardioversion.

Elective direct-current cardioversion was performed in three patients with atrial fibrillation. Transient ST-segment elevation on monitored leads, lasting seconds, was recorded after cardioversion in all three patients. LDH, CPK isoenzymes, and myocardial scintigraphy did not reveal myocardial damage. Elective cardioversion should be performed with caution, for the potential for cardiac damage cannot be ignored.

Giant coronary pseudoaneurysm. Five-year follow-up after bypass grafting.

A roentgenogram of the shoulder in a 25-year-old man with an athletic injury revealed a large mass along the left heart border. Evaluation with coronary arteriography established the diagnosis of a massive aneurysm of the left anterior descending coronary artery. The aneurysm was excised and a saphenous vein bypass graft was placed into the distal artery. Histologic examination revealed that the excised segment was a false aneurysm. Five years postoperatively, the patient is asymptomatic and the graft remains widely patent.

Coronary ostial stenosis in Takayasu's arteritis.

A patient with Takayasu's arteritis with left coronary ostial narrowing is presented. The dramatic clinical and pathologic findings are discussed in detail. Emphasis is placed on making the diagnosis as soon as possible, in order to expedite bypass surgery to prolong life.

Björk-Shiley mitral valvular dehiscence. Documented by radiography, echocardiography, fluoroscopy, and cineangiography.

This case report presents combined radiographic, echocardiographic, fluoroscopic, and cineangiographic findings of the dehiscence of a Bjork-Shiley mitral prosthetic valve. The valvular dehiscence was confirmed at surgery. A distinct rounding of the opening phase of the valve was recorded on the echocardiogram. Other clinical evidence, documenting the severe valvular dehiscence, is reported in detail. Non-invasive procedures are therefore invaluable in recording prosthetic valvular dysfunction.

Acromegaly and the heart. An echocardiographic study.

Twenty-seven patients with acromegaly had echocardiograms performed to delineate the ventricular septum, left ventricular posterior wall and mitral valve. Left ventricular function was assessed by calculating the systolic internal dimensional shortening of the left ventricle. Six patients met the criteria for asymmetric septal hypertrophy and eight had concentric left ventricular hypertrophy. The remaining 13 patients were categorized as "normal," although six had septal measurements greater than 11 mm. The group with asymmetric septal hypertrophy had significantly greater percentage of internal dimensional shortening during systole than either the normal group (p less than 0.05) or the group with left ventricular hypertrophy (p less than 0.01). Initial mean growth hormone levels were considerably higher in the group with left ventricular hypertrophy than in the normal group (93 versus 34 ng/ml). Thus, echocardiographic abnormalities are common in acromegaly, and patients with asymmetric septal hypertrophy and acromegaly appear to have significantly increased ventricular ejection. Many of the patients with left ventricular hypertrophy have no evidence of clinical cardiovascular disease, and their left ventricular hypertrophy may be related to higher initial growth hormone levels.