Splenic Infarct: A Rare Presentation in a Pediatric Patient.

A previously healthy 16-year-old male presented with a two day history of persistent epigastric pain. His physical examination was significant for tenderness in the left hypochondriac region with a palpable spleen 2cm below the left sub-costal margin. A CT scan of the abdomen showed a splenic infarct. Heterophile and EBV VCA IgM antibody test were positive. This is a rare case of infectious mononucleosis presenting with splenic infarct in an adolescent male without co-morbidities.

Cardiac tests in asymptomatic type 2 diabetics.

OBJECTIVE: To evaluate the use of noninvasive procedures for the detection of myocardial ischemia and its relation with other coexistent clinical factors in patients with asymptomatic type 2 diabetes mellitus. SUBJECTS AND METHODS: A total of 42 patients with type 2 diabetes mellitus, aged 41-72 years with no clinical history suggestive of coronary heart disease, were evaluated for silent myocardial ischemia by stress cardiac exercise tolerance test (ETT), 12-lead electrocardiography (ECG), transthoracic echocardiography and stress myocardial perfusion scan using technetium-99m tetrofosmin. RESULTS: Eleven patients (26.2%) showed an ischemic pattern on ETT, the resting ECG was suggestive of ischemia in only 2 (4.8%), echocardiography showed diastolic dysfunction in 9 (21.4%), and the stress myocardial perfusion scan was ischemic in 3 (7.3%). For subjects over the age of 57, a significant difference was found between age and ischemic ETT (p = 0.026) and diastolic dysfunction by echocardiography (p = 0.044). Patients with microalbuminuria and/or diastolic dysfunction were more likely than others to have ischemic ETT (p = 0.036 and 0.024, respectively) and patients with diastolic dysfunction had a higher prevalence of ischemic ETT. There was no relation between ischemic ETT and other major cardiac risk factors (hypertension, dyslipidemia, smoking, sex, duration of diabetes, BMI, and glycated hemoglobin levels). CONCLUSION: The cardiac ETT was most helpful for detecting myocardial ischemia in asymptomic type 2 diabetics. For equivocal ETT findings, echocardiography is recommended. The prevalence of myocardial ischemia was high in patients with type 2 diabetes mellitus.

The late open artery hypothesis--a decade later.

BACKGROUND: Early reperfusion after myocardial infarction has been proved to preserve left ventricular function and reduce mortality. However, a significant number of patients have persistent occlusion of the infarct-related artery late (days to weeks) after myocardial infarction because of ineligibility for thrombolytic therapy, failure of reperfusion, or reocclusion. METHODS: In this report we review the data on the potential mechanisms and benefits of late reperfusion and present prospective data on the incidence of and current practice patterns for the management of persistently occluded infarct-related arteries late after myocardial infarction. RESULTS: Although several studies have associated late patency of the infarct-related artery with improved long-term clinical outcome, they were nonrandomized and reflect selection bias. Furthermore, data on late patency from the largest study, Global Utilization of Steptokinase and Tissue Plasminogen Activator for Occluded Arteries (GUSTO-I), failed to confirm independent benefits of an open infarct-related artery 1 year after myocardial infarction. The randomized data on the effects of percutaneous transluminal coronary angioplasty for occluded infarct-related arteries late after myocardial infarction are limited and inconclusive. CONCLUSIONS: The hypothesis that late reperfusion by percutaneous coronary intervention days to weeks after myocardial infarction results in improved long-term clinical outcomes in asymptomatic patients with occluded infarct-related artery is currently being tested in the randomized, multicenter Occluded Artery Trial.

Antiarrhythmic drug use in the implantable defibrillator arm of the Antiarrhythmics Versus Implantable Defibrillators (AVID) Study.

BACKGROUND: Previous retrospective or observational series suggest that many patients with an implantable cardioverter-defibrillator (ICD) will be treated with antiarrhythmic drugs (AADs) to modify the frequency or manifestation of recurrent ventricular arrhythmias. The relative clinical benefit, however, is uncertain, and deleterious interactions can occur. The objective of this clinical investigation was to study the need for, and effects of, concomitant AAD use with the ICD in a prospectively defined cohort. METHODS: All patients randomly assigned to the ICD arm of the Antiarrhythmics Versus Implantable Defibrillators (AVID) study were followed for the addition of class I or III AADs ("crossover") after hospital discharge. Addition of AADs was strictly regulated by AVID protocol. The timing and reasons for crossover and the effects on ventricular arrhythmia recurrence were analyzed. Patients were excluded if they required AADs before hospital discharge after index arrhythmias or if they had no ventricular arrhythmia before initiation of AADs. RESULTS: After a median follow-up of 135 days, 81 (18%) of the 461 eligible patients required AADs and formed the crossover group. The primary reason for crossover was frequent ICD shocks in 64% of patients. The most common AAD selected was amiodarone (in 42%). Independent predictors of crossover were lower ejection fraction, absence of ventricular fibrillation, or presence of nonsyncopal ventricular tachycardia at presentation, prior unexplained syncope, female sex, and history of cigarette smoking. Before AAD use, the 1-year arrhythmia event rate was 90%; after AAD, the event rate was only 64% (P =.0001). The time to first event was extended from 3.9 +/- 0.7 months to 11.2 +/- 1.8 months. There were 1.4 +/- 3.7 fewer ICD therapy events (P =.005) after crossover, predominantly accounted for by reduction in shocks rather than antitachycardia pacing therapies. CONCLUSIONS: The majority of patients who receive ICDs for sustained ventricular tachycardia or ventricular fibrillation can be treated without AADs. Most commonly, AADs are added to combat frequent ICD shocks, which are successfully reduced by AAD therapy.

Clinical and echocardiographic characteristics of left atrial spontaneous echo contrast in sinus rhythm.

OBJECTIVES: In this study we attempt to define the clinical and echocardiographic characteristics of patients with left atrial spontaneous echo contrast (LASEC) in sinus rhythm (NSR). BACKGROUND: Left atrial spontaneous echo contrast in atrial fibrillation (AF) is associated with increased risk of thromboembolism. Little is known about its significance in NSR. METHODS: We reviewed reports of 1,288 transesophageal echocardiogram (TEE) studies done with a 5 MHz probe. Patients with swirling LASEC who were in NSR during TEE were analyzed. We compared them with a control group of 45 age matched patients selected to have NSR, left atrium (LA) > 4.0 cm but no SEC. RESULTS: Spontaneous echo contrast in NSR was noted in 24 patients (2%) and formed our study group. All patients with SEC had enlarged LA, mean 5.6 cm +/- 0.6 cm. There was a higher prevalence of cerebrovascular accident (CVA) in patients with SEC when compared with controls with no SEC, 83% versus 56%, p = 0.02. Patients with SEC had larger LA, 5.6 versus 4.9 cm, p < 0.0001 and lower mean peak left atrial appendage emptying velocity (LAAEV), 38 versus 56 cm/s, p = 0.001. Thirteen percent of patients with SEC had LA thrombus as compared with none in the control group, p = 0.02. By multivariate analysis, SEC in NSR was found to be associated with CVA, larger LA size and decreased mean LAAEV. Even after adjusting for LA size, patients with SEC had a higher prevalence of CVA than controls, p = 0.03. CONCLUSIONS: Spontaneous echo contrast in NSR occurs in patients with significantly dilated LA and depressed atrial function. Left atrial thrombus is noted in 13% of such patients despite NSR. Spontaneous echo contrast in NSR is associated with a higher prevalence of CVA. Further, SEC is found to be an independent and more powerful correlate of CVA than reduced LAAEV or atrial size. These data indicate that LASEC in NSR is a prothombotic condition.

Early reperfusion, late reperfusion, and the open artery hypothesis: an overview.

Randomized clinical trials have clearly shown the beneficial effects of early reperfusion within 12 hours, and possibly up to 24 hours, after acute myocardial infarction (AMI). The data on late reperfusion beyond 24 hours are less convincing. Many studies show that an open infarct-related artery after MI, irrespective of the initial reperfusion strategy, is independently associated with improved long-term clinical outcome. However, similar analysis of the large Global Utilization of Streptokinase and tPA for Occluded Arteries (GUSTO) 1 study did not confirm this finding. It is unclear whether mechanical reperfusion of an occluded infarct-related artery late after MI (>24 hours) in asymptomatic patients will confer long-term benefits. The late open artery hypothesis, which proposes several mechanisms by which late reperfusion may offer benefit, remains to be tested in a large clinical trial. This overview focuses on the definitions of early reperfusion, late reperfusion, the relationship between timing of reperfusion and prognosis after AMI, and the late open artery hypothesis.

The ataxia-telangiectasia gene product, a constitutively expressed nuclear protein that is not up-regulated following genome damage.

The product of the ataxia-telangiectasia gene (ATM) was identified by using an antiserum developed to a peptide corresponding to the deduced amino acid sequence. The ATM protein is a single, high-molecular weight protein predominantly confined to the nucleus of human fibroblasts, but is present in both nuclear and microsomal fractions from human lymphoblast cells and peripheral blood lymphocytes. ATM protein levels and localization remain constant throughout all stages of the cell cycle. Truncated ATM protein was not detected in lymphoblasts from ataxia-telangiectasia patients homozygous for mutations leading to premature protein termination. Exposure of normal human cells to gamma-irradiation and the radiomimetic drug neocarzinostatin had no effect on ATM protein levels, in contrast to a noted rise in p53 levels over the same time interval. These findings are consistent with a role for the ATM protein in ensuring the fidelity of DNA repair and cell cycle regulation following genome damage.

Pattern of cardiac calcification in tropical endomyocardial fibrosis.

Over a two-year period we investigated 55 patients with endomyocardial fibrosis, using two-dimensional echocardiography, color-coded echocardiography, and image intensifier fluoroscopy, to delineate the regional distribution of cardiac calcification. Thirty five patients (64%) were found to have calcification of the ventricular walls. Calcific deposits were seen in the right ventricle in 26(59%) patients and in the left ventricle in 16(44%) patients. All patients who showed calcification were in severe cardiac failure indicating late stage of the disease. When image intensifier fluoroscopy was taken as the gold standard, echocardiography had a sensitivity of 100% and a specificity of 98% in detecting cardiac calcification. The high incidence of calcification in the ventricular walls in the present study is apparently due to the systematic use of two-dimensional echocardiography and image intensifier fluoroscopy.

Echocardiographic features of tropical endomyocardial disease in South India.

Fifteen patients with tropical endomyocardial disease which had been proved angiographically were studied using M-mode and cross-sectional echocardiography to determine the extent to which specific features of this disease could be recognised by these non-invasive methods. Tethering of the posterior mitral valve leaflet to the ventricular wall in combination with areas of echo-dense material in the posterior left ventricular wall and associated papillary muscle appeared to be a constant diagnostic feature of this disease. Colour coding of regional echo amplitude showed high intensity echoes in a distribution corresponding closely to that of the fibrosis known to occur in this condition. Though M-mode echocardiography did not contribute diagnostic information, it was useful in defining the functional consequences of myocardial or mitral valve disease. Digitisation of records allowed a restrictive pattern of left ventricular filling to be observed. It was concluded that cross-sectional echocardiography, particularly when supplemented by colour coded amplitude processing, can make a confident non-invasive diagnosis of tropical endomyocardial disease and so could be useful in assessing its progression or response to treatment.