Transient right but not left ventricular dysfunction after strenuous exercise at high altitude.

OBJECTIVES: We sought to evaluate whether prolonged exercise in ultramarathon runners results in left ventricular (LV) damage. BACKGROUND: Strenuous exercise has been reported to cause LV damage. METHODS: Fourteen runners who completed an ultramarathon at high altitude underwent echocardiography, finger-tip oximetry and blood measurements of cardiac troponin I (cTnI) and creatine kinase, MB fraction (CK-MB) levels before, immediately after and 1 day after the race. RESULTS: At baseline, the echocardiograms showed normal LV and right ventricular (RV) size and function in all subjects, as well as mild tricuspid regurgitation in nine subjects, with normal estimated pulmonary artery systolic pressure (mean 28 mm Hg). At baseline, all oxymetric readings and CK-MB measurements were normal, and cTnI was undetectable. Immediately after the race, the echocardiograms showed the expected augmentation of global and segmental LV function in all subjects. Although the RV was normal in nine subjects, five developed marked RV dilation and hypokinesia, paradoxic septal motion, pulmonary hypertension and wheezing. CK-MB values were elevated in all subjects. In all but one subject cTnI was undetectable. In that subject there was a small elevation in cTnI accompanied by severe RV dysfunction and pulmonary hypertension. At the 1-day follow-up study, the echocardiographic measurements had normalized in all subjects. CONCLUSIONS: In trained athletes, strenuous exercise at high altitude did not result in LV damage. However, wheezing, reversible pulmonary hypertension and RV dysfunction occurred in a third of those completing the race. The incidence and pathogenesis of these findings remain to be determined.

Myocardial injury in critically ill patients. A frequently unrecognized complication.

OBJECTIVE: To determine the incidence and effect of unrecognized cardiac injury in critically ill patients. DESIGN: Prospective, blinded, single-center study. SETTING: The medical and respiratory intensive care unit of an academic health center. PATIENTS: Two hundred nine patients (224 admissions). MAIN OUTCOME MEASURES: Daily measurement of levels of cardiac troponin I, a sensitive, highly specific, and long-lived marker of myocardial injury. Concurrently, signs and symptoms potentially related to myocardial ischemia were tabulated by blinded investigators. All clinical evaluation and management decisions were made by the physicians responsible for the care of the patient. RESULTS: Thirty-two (15%) of the 209 patients had evidence of myocardial damage based on elevated levels of cardiac troponin I. Only 12 (37%) of these 32 patients were diagnosed as having acute myocardial infarction by the intensive care unit staff. Cardiac damage was unrecognized in the other 20 (63%). Unrecognized cardiac injury was more common in young patients and in blacks. Mortality in patients with myocardial injury that was recognized (42%) or unrecognized (40%) was higher than in those without myocardial injury (15%) (P < .001). Patients with cardiac injury were more frequently hypotensive (75% vs 50%; P = .007) and in need of mechanical ventilation (66% vs 27%; P < .001) and had longer intensive care unit stays (5.3 vs 3.1 days; P < .007) than patients without cardiac injury. CONCLUSION: The incidence of myocardial injury defined by elevated levels of cardiac troponin I was unexpectedly high and associated with increased morbidity and mortality. Clinically, it was often unrecognized.

Internal Medicine chief residents suggest need to improve health care delivery and public policy education. Internal Medicine Center to Advance Research and Education.

The primary objective in medical training remains skill development in the delivery of medical care through the understanding of bedside data collection, natural history of disease, use of diagnostic tools and the influence of therapy--all applied to a specific patient. More recently, also considered important is training on the broader issues of health care delivery and public policy, especially since the environment of medicine is changing rapidly. With limited curricular time these issues must compete with the traditional and important clinical training. To evaluate how these subjects have been included in internal medicine training, the Resident Physicians Section (RPS) of the American Society of Internal Medicine (ASIM) sponsored a survey of United States internal medicine chief residents which was conducted by the Internal Medicine Center to Advance Research and Education (IMCARE). The objectives of the study were to 1) study the extent of training on health care delivery and public policy issues offered to residents by internal medicine residency programs; 2) assess training opportunities now available; and 3) determine areas of study not fulfilling perceived needs. The questionnaire contained 12 questions. Chief residents rated the 1) quality of their program in preparing residents on health care delivery, public policy issues and practice management; 2) level of instruction provided on 12 topics; and 3) degree of priority these same topics should have. Respondents were asked to identify 1) any other relevant areas their residency program covered particularly well; 2) the amount of time which should be devoted to these socioeconomic topics in each year of training; and 3) the most appealing formats for learning about these topics. Despite the rapidly growing influence of socioeconomic issues on medical practice, many chief residents perceive that important topics are not being addressed adequately. This study provides information on areas addressed well and topics that should receive greater attention. Recommendations are made for further studies and strategies to increase the emphasis on socioeconomic topics during medical education.

Successful treatment of invasive pulmonary aspergillosis in the immunocompromised host.

We have reported the successful treatment of a patient with acute leukemia complicated by pulmonary aspergillosis, a commonly fatal situation. Specific diagnosis was obtained easily by transbronchial lung biopsy. Our therapeutic approach included aggressive treatment of both the underlying malignant process and the aspergillosis with a combination of amphotericin B and rifampin.