Cardiac dysfunction in exacerbations of chronic obstructive pulmonary disease is often not detected by electrocardiogram and chest radiographs.

BACKGROUND: Cardiac dysfunction is common in exacerbations of chronic obstructive pulmonary disease (COPD), even in patients without clinically suspected cardiac disorders. AIM: To investigate associations between electrocardiogram (ECG) and chest radiograph abnormalities and biochemical evidence of cardiac dysfunction (N-terminal pro-B-type natriuretic peptide and troponin T) in patients hospitalised with exacerbations of COPD at Waikato Hospital. METHODS: Independent examiners, blinded to NT-proBNP and troponin T levels, assessed ECG for tachycardia, atrial fibrillation, ventricular hypertrophy and ischaemic changes in 389 patients and chest radiographs for signs of heart failure in 350 patients. Associations between electrocardiographic and radiographic abnormalities with at least moderate interrater agreement and cardiac biomarkers were analysed. RESULTS: High NT-proBNP values (>220 pmol/L) were associated with atrial fibrillation (22 vs 6%), right ventricular hypertrophy (24 vs 15%), left ventricular hypertrophy (15 vs 4%), ischaemia (59 vs 33%) and cardiomegaly (42 vs 20%). High troponin T values (>0.03ug/L or high-sensitivity >50 ng/L) were associated with tachycardia (65 vs 41%), right ventricular hypertrophy (26 vs 15%) and ischaemia (60 vs 36%). None of the electrocardiographic or radiographic abnormalities was sensitive or specific for cardiac biomarker abnormalities. Ischaemia on ECG was the best indicator for raised NT-proBNP (sensitivity 59%, specificity 67%). Tachycardia and ischaemia were the best indicators of raised troponin T (sensitivity 65 and 60%, specificity 59 and 64% respectively). CONCLUSIONS: ECG and chest radiograph abnormalities have poor sensitivity and specificity for diagnosing acute cardiac dysfunction in exacerbations of COPD. Cardiac biomarkers provide additional diagnostic information about acute cardiac dysfunction in exacerbations of COPD.

Delay in cutaneous melanoma diagnosis: Sequence analyses from suspicion to diagnosis in 211 patients.

Advanced melanoma is an incurable disease with complex and expensive treatments. The best approach to prevent melanoma at advanced stages is an early diagnosis. A knowledge of factors associated with the process of detecting cutaneous melanomas and the reasons for delays in diagnosis is essential for the improvement of the secondary prevention of the disease.Identify sociodemographic, individual, and medical aspects related to cutaneous melanoma diagnosis delay.Interviews evaluated the knowledge of melanoma, signals, symptoms, persons who were suspected, delays in seeking medical attention, physician's deferrals, and related factors of 211 patients.Melanomas were self-discovered in 41.7% of the patients; healthcare providers detected 29.9% of patients and others detected 27%. The main component in delay was patient-related. Only 31.3% of the patients knew that melanoma was a serious skin cancer, and most thought that the pigmented lesion was not important, causing a delay in seeking medical assistance. Patients (36.4%) reported a wait interval of more than 6 months from the onset of an observed change in a pigmented lesion to the first visit to a physician. The delay interval from the first physician visit to a histopathological diagnosis was shorter (<1 month) in 55.5% of patients. Improper treatments without a histopathological confirmation occurred in 14.7% of patients. A professional delay was related to both inappropriate treatments performed without histopathological confirmation (P = 0.003) and long requirements for medical referrals (P < 0.001).A deficient knowledge in the population regarding melanoma and physicians' misdiagnoses regarding suspicious lesions contributed to delays in diagnosis.

Sweet's syndrome: study of 73 cases, emphasizing histopathological findings.

BACKGROUND: Sweet's syndrome refers to a set of cutaneous, systemic and histopathological alterations that occur in response to different stimuli, in a similar way to that occurring in erythema nodosum, erythema multiforme and leukocytoclastic vasculitis. The syndrome has been described in association with conditions such as infections, pregnancy, the use of certain medications and malignancy. OBJECTIVES: To evaluate the clinical and histopathological alterations occurring in this syndrome and to assess the association between these alterations and other conditions. METHODS: A retrospective study of 73 cases was conducted, evaluating data on the microscopic examination of skin lesions, as well as clinical and laboratory data. RESULTS: The majority of the patients were female (83.0%), white (49.2%) and between 30 and 60 years of age (73.8%). The principal alterations found were: erythymatous plaques (76.9%), papules (43.0%), pseudo-vesiculation (PV) (38.4%) and target lesions (18.5%). With respect to the associated conditions, upper respiratory tract infections (15.4%) and the use of medication (10.8%) were the most common. Other associations, albeit represented by only one case each, were: Hodgkin's lymphoma, pregnancy, ulcerative colitis, polycythemia vera and lupus erythematosus in a patient with acquired immune deficiency syndrome (AIDS). The principal microscopic findings were: neutrophils with leukocytoclasia (98.6%), collagen degeneration (87.7%), edema (74.0%) and PV (38.4%). The presence of eosinophils (41.1%) ranged from rare to abundant and was usually unrelated to the use of medication. Inflammatory infiltrate reached the deep epidermal layer in 47.9% of cases and panniculitis was found in 80.0% of cases in which the hypodermis was affected (10 cases). CONCLUSIONS: In general, these findings are in agreement with results published in the literature, emphasizing the frequent finding of eosinophils unrelated to drug use, panniculitis and the rare association with Hodgkin's lymphoma. This is the fifth report of an association between Sweet's syndrome and Hodgkin's disease.

Effects of smoking cannabis on lung function.

Although cannabis (or marijuana) is the world's most widely-used illicit drug, there has been surprisingly little research into its effects on respiratory health. Part of the problem is the inherent difficulty of studying the long-term effects of an illegal habit. It has often been assumed that smoking cannabis will have similar long-term effects to smoking tobacco. Several recent observational studies suggest that this is not the case and that cannabis has quite different effects on the lung function. There are consistent findings that smoking cannabis is associated with large airway inflammation, symptoms of bronchitis, increased airway resistance and lung hyperinflation. The evidence that smoking cannabis leads to features of chronic obstructive pulmonary disease, such as airflow obstruction and emphysema is not convincing. However, there are numerous case reports of bullous emphysema among cannabis smokers. These findings have not been confirmed in systematic analytical studies and probably represent uncommon adverse effects in very heavy cannabis smokers. There is now additional controversial evidence that cannabis is at least an occasional cause of respiratory malignancies, but again the evidence is inconclusive.

Síndrome de Sweet: estudo de 73 casos, com ênfase nos achados histopatológicos / Sweet's syndrome: study of 73 cases, emphasizing histopathological findings

FUNDAMENTOS: A síndrome de Sweet corresponde a um conjunto de alterações cutâneas, sistêmicas e histopatológicas como resposta a diversos estímulos, semelhantes ao eritema nodoso, ao eritema multiforme e à vasculite leucocitoclásica. São descritas condições associadas como infecção, gravidez, uso de drogas e malignidades. OBJETIVOS: Avaliar as alterações clínicas e histopatológicas da síndrome, relacionando-a a outras condições. MÉTODO: Estudo retrospectivo de 73 casos com avaliação microscópica de lesões cutâneas, dados clínicos e laboratoriais. RESULTADOS: Houve predomínio de mulheres (83,0 por cento), brancas (49,2 por cento), entre a quarta e a sexta décadas de vida (73,8 por cento). Placas eritematosas (76,9 por cento), pápulas (43,0 por cento), pseudovesiculação (PV) (38,4 por cento) e lesões em alvo (18,5 por cento) foram as principais alterações. Entre as condições associadas, infecções de vias aéreas (15,4 por cento) e uso de drogas (10,8 por cento) foram as mais frequentes. Outras associações, representadas por um caso cada, foram: linfoma de Hodgkin, gravidez, colite ulcerativa, policitemia vera e lúpus eritematoso em paciente com Aids. Neutrófilos com leucocitoclasia (98,6 por cento), degeneração do colágeno (87,7 por cento), edema (74,0 por cento) e PV (38,4 por cento) foram os principais achados microscópicos. Eosinófilos estiveram presentes (41,1 por cento) de raros a abundantes e, em geral, não relacionados ao uso de drogas. O infiltrado inflamatório atingiu a derme profunda em 47,9 por cento das vezes e encontrou-se paniculite em 80,0 por cento dos casos nos quais a hipoderme estava representada (10 casos). CONCLUSÕES: Os achados, de modo geral, coincidem com os da literatura, destacando-se: frequente participação de eosinófilos sem correlação com a ingestão de medicamentos, paniculite e rara associação com linfoma de Hodgkin, sendo este o quinto relato de tal ocorrência, segundo o conhecimento dos autores.

BACKGROUND: Sweet's syndrome refers to a set of cutaneous, systemic and histopathological alterations that occur in response to different stimuli, in a similar way to that occurring in erythema nodosum, erythema multiforme and leukocytoclastic vasculitis. The syndrome has been described in association with conditions such as infections, pregnancy, the use of certain medications and malignancy. OBJECTIVES: To evaluate the clinical and histopathological alterations occurring in this syndrome and to assess the association between these alterations and other conditions. METHODS: A retrospective study of 73 cases was conducted, evaluating data on the microscopic examination of skin lesions, as well as clinical and laboratory data. RESULTS: The majority of the patients were female (83.0 percent), white (49.2 percent) and between 30 and 60 years of age (73.8 percent). The principal alterations found were: erythymatous plaques (76.9 percent), papules (43.0 percent), pseudo-vesiculation (PV) (38.4 percent) and target lesions (18.5 percent). With respect to the associated conditions, upper respiratory tract infections (15.4 percent) and the use of medication (10.8 percent) were the most common. Other associations, albeit represented by only one case each, were: Hodgkin's lymphoma, pregnancy, ulcerative colitis, polycythemia vera and lupus erythematosus in a patient with acquired immune deficiency syndrome (AIDS). The principal microscopic findings were: neutrophils with leukocytoclasia (98.6 percent), collagen degeneration (87.7 percent), edema (74.0 percent) and PV (38.4 percent). The presence of eosinophils (41.1 percent) ranged from rare to abundant and was usually unrelated to the use of medication. Inflammatory infiltrate reached the deep epidermal layer in 47.9 percent of cases and panniculitis was found in 80.0 percent of cases in which the hypodermis was affected (10 cases). CONCLUSIONS: In general, these findings are in agreement with results published in the literature, emphasizing the frequent finding of eosinophils unrelated to drug use, panniculitis and the rare association with Hodgkin's lymphoma. This is the fifth report of an association between Sweet's syndrome and Hodgkin's disease.

Enlarged epitrochlear lymph nodes: an old physical sign revisited.

Few doctors routinely examine the epitrochlear glands as part of their physical examination of a patient. No palpable epitrochlear nodes were detected in 140 healthy subjects, but palpable epitrochlear nodes were present in 27% of 184 patients with diseases in which lymphadenopathy occurs. Whilst epitrochlear nodes are commonly enlarged in specific acute, subacute, and chronic infections, they are not enlarged in the mild, transient, non-specific febrile illnesses with cervical lymphadenopathy of children and young adults. Enlarged epitrochlear glands provide a useful discriminatory sign in the diagnosis of glandular fever. Enlargement of these nodes is common in most of the lymphoproliferative disorders except Hodgkin's disease. In rheumatoid arthritis their palpability indicates activity of hand joints. The examination of epitrochlear nodes should form part of the routine physical assessment of any ill patient.

Observations on the relationship between digital heat loss and systemic hemodynamics in patients with heart disease.

A concomitant study of finger heat discharge and systemic hemodynamics was undertaken in a series of 19 patients (mean age 54 years) suffering from various forms of heart disease. Finger heat discharge, as measured by calorimetry, was found to correlate significantly with mean circulation time (-0.760), cardiac index (+0.649), systemic vascular resistance (-0.615), stroke work index (+0.649), mean pulmonary artery pressure (-0.596), mean pulmonary capillary wedge pressure (-0.554), stroke index (+0.541), appearance time (-0.502) and mean right atrial pressure (-0.453). There was no significant correlation between finger heat discharge and mean arterial blood pressure, LV dp/dtmax, and heart rate. An effect of heart failure on finger heat discharge was found. When evidence of forward failure and also possibly backward failure was found, mean finger heat discharge was significantly diminished. When both forward and backward failure were present together, mean finger heat discharge fell still further.

The effect of mild-to-moderate mental stress on coronary hemodynamics in patients with coronary artery disease.

Eleven men with coronary artery disease were studied to determine whether they would manifest inappropriate coronary vasoconstriction in response to mental stress. Mental stress was induced by having the patient perform difficult mental arithmetic in time with a clicking metronome. Aortic blood pressure and thermodilution coronary sinus blood flow were recorded continuously before and during the mental arithmetic. For the group, heart rate rose from 70 to 82 beats/min, systolic blood pressure rose from 161 to 181 mm Hg and diastolic blood pressure rose from 71 to 78 mm Hg. Coronary resistance decreased by 16%. The index of myocardial oxygen consumption rose by 40%, and there was an equivalent rise in coronary sinus blood flow of 41%, with no changes in coronary arteriovenous oxygen difference. Because the increase in myocardial oxygen consumption was accompanied by a proportional increase in coronary sinus blood flow, a decrease in coronary resistance and no change in myocardial oxygen extraction, we conclude that the response of patients with coronary artery disease to at least moderately severe mental stress is not characterized by abnormal coronary vasoconstriction.

The effect upon coronary blood flow of coronary ostial intubation with an angiographic catheter.

Fifty-two patients undergoing cardiac catheterization were studied to determine whether intubation of the coronary ostium in the course of coronary angiographic studies interferes with coronary blood flow. Pressure at the tip of the catheter and coronary sinus blood flow were measured continuously during insertion of a No. 7.2 French Judkins' catheter into the left coronary ostium and during withdrawal of the catheter from it. In 48 of the 52 patients, there was no change in blood flow related to manipulation of the catheter. In four patients, either a drop in flow following insertion of the catheter or a rise following withdrawal or both were recorded. Two of these four patients had high-grade obstruction of the main left coronary artery, and in the other two the catheter inadvertently advanced and became wedged. In all four cases, reduction in coronary flow was indicated by a drop in or "ventricularization" of the catheter-tip pressure. It is concluded that in the large majority of instances, intubation of the coronary ostium during coronary angiographic studies causes no interference with resting coronary blood flow, but that monitoring of catheter-tip pressure is an important, as well as a valid, procedure for detecting such an interference if it should occur.

The effect of intracoronary injection of contrast medium upon coronary blood flow.

The changes in coronary blood flow in response to intracoronary injection of 3 ml of 76% Renografin were studied in 47 patients using the thermodilution technique for continuous measurement of coronary sinus blood flow. Within seconds after left coronary injection, an increase in coronary sinus flow began which peaked at an average of 53% above control in 5-10 seconds. There was a corresponding decrease in coronary resistance. Flow returned to control level in almost all patients within one minute of injection. Twenty-four of 35 patients had no change in coronary sinus flow in response to right coronary injection. This can be explained by the fact that most of the venous flow from the right coronary artery returns in such a way that it cannot be measured by the coronary sinus catheter. Of the eleven patients who did show an increase, seven had angiographically documented right to left collaterals, suggesting that the increase in flow was the result of vasodilatation of the left coronary bed by contrast arriving via the right to left collaterals. The percent changes in flow and resistance in response to left coronary injection were isgnificantly greater in the 13 normals than in the 34 with obstructive disease of the left coronary artery (P lessthan 0.01). Flow rose 70 plus or minus 27% (mean plus or minus standard deviation) in the normals versus 46 plus or minus 25% in the patients with coronary artery disease, while resistance fell 44 plus or minus 9% versus 33 plus or minus 11%. The differences, however, were not sufficient for these changes to be of value in the assessment of the degree of impairment of the coronary arterial bed in the individual patient.

Surgical therapy in acute ischemic syndromes.

Despite increasing enthusiasm about the treatment of symptomatic angina pectoris by direct revascularization surgery, there appropriately continues to be concern about the effects of such therapy. While it is generally accepted that surgery is effective in relieving anginal pain in upwards of 80% of patients undergoing aortocoronary bypass, reservations focus on the possibilities that such therapy may increase the incidence of infarction (postoperative), accelerate the atherosclerotic process, and shorten longevity, primarily because of the increased early operative mortality. While these contentions may or may not be true for the majority of patients who undergo such therapy, there is accumulating experience that in certain well-defined subsets, surgery does favorably affect the prognosis of the disease. Patients with preinfarction angina constitute one such subset of patients with coronary atherosclerosis. The all-inclusive surgical mortality for 106 consecutive cases was 3.8%, and 86% of the survivors are asymptomatic. Actuarial analysis of follow-up data reveals that this survival rate is essentially constant through the first 36 months after surgery. On the basis of this experience we feel that patients with preinfarction angina present a therapeutic opportunity in which the ideal goal of preventive medical care can be achieved by early identification, study and surgery.

The rationale for surgery in preinfarction angina.

Of 123 patients with identical clinical criteria for preinfarction angina, 35 were treated medically and 88 surgically in a nonrandomized manner. There was no statistical difference between these two therapeutic groups in regard to age range, average age, sex distribution, number and distribution of prior myocardial infarction, and duration of chronic and acute anginal symptoms. With medical therapy, 32 sustained a myocardial infarction, and 14 (40 per cent) of these died within 1 month of hospital admission. Thirteen of 21 survivors or 37 per cent of the original group are asmptomatic on continuing medical therapy an average of 15 months after discharge. The surgical patients were studied by catherization and anigiography and underwent an early operation. Eight (9.4 per cent) demonstrated evidence of postoperative infarction, and 3 (3.4 per cent) died after the operation. Seventy-one (84 per cent) are completely asymptomatic and 6 are less symptomatic an average of 17 months after the operation. Actuarial analysis of the follow-up data reveals that the initial significant difference in survival between the two groups is maintained through the first 36 months. On the basis of this experience, we suggest that surgical intervention is the therapy of choice in patients with preinfarction angina.