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Computed tomographic (CT) findings of cerebral and cerebellar calcification are described in three American adults with raised serum lead levels and known exposure to lead for 30 or more years. Calcification patterns were punctiform, curvilinear, speck-like, and diffuse and were found in the subcortical area, basal ganglia, vermis, and cerebellum. Admission serum lead levels ranged from 54 to 72 micrograms/dl (normal, 0-30 micrograms/dl). Nonspecific neurologic manifestations consisted of dementia, diminished visual acuity, peripheral neuropathy, syncope, dizziness, nystagmus, easy fatigue, and back pain. Two patients developed chronic renal disease and hypertension; in both cases, serum parathormone was elevated. Blood, calcium, and phosphorus were normal in all three. No other structural abnormalities were observed with CT. Although the pathophysiologic mechanism of these findings remains poorly understood, it is suggested that chronic lead exposure should be included in the differential diagnosis of unexplained intracranial calcifications in adults.
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PMID:Intracranial calcification in adults with chronic lead exposure. 348 74

Eight physically trained and eight untrained, unacclimated men walked on a treadmill at 30% of their maximum oxygen consumption up to 3.5 h in a thermoneutral [20 degrees C/40% relative humidity (RH)], a warm humid (30 degrees C/80% RH), and a hot dry (40 degrees C/20% RH) environment while wearing industrial work clothing. Their oxygen consumption, rectal and skin temperatures, sweating, cardiac output, heart rate, stroke volume, and peripheral blood pressure were measured during the tests. Thirteen of the 32 heat stress tests were prematurely stopped due to high rectal temperature, high heart rate, subjective fatigue, or heat syncope. The physiological strain, as indicated by the rectal temperature and heart rate, was not significantly different between the warm humid and hot dry environments (wet bulb globe temperature approximately 28 degrees C). The rectal temperature and heart rate responses of the physically trained and untrained subjects did not differ in any of the environments. In the heat, the heart rate was significantly higher than in the thermoneutral environment, but because of the markedly reduced stroke volume the average cardiac output was not different between the three environments. The impaired work performance in the heat seemed mainly to be related to the circulatory instability accompanying the increased cutaneous circulation.
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PMID:Circulatory and thermal responses of men with different training status to prolonged physical work in dry and humid heat. 357 43

A national registry was begun in 1981 to collect data from 32 centers on patients diagnosed by uniform criteria as having primary pulmonary hypertension. Entered into the registry were 187 patients with a mean age (+/- SD) of 36 +/- 15 years (range, 1 to 81), and a female-to-male ratio of 1.7:1 overall. The mean interval from onset of symptoms to diagnosis was 2 years. The most frequent presenting symptoms included dyspnea (60%), fatigue (19%), and syncope (or near syncope) (13%). Raynaud phenomenon was present in 10% (95% of whom were female) and a positive antinuclear antibody test, in 29% (69% female). Pulmonary function studies showed mild restriction (forced vital capacity [FVC], 82% of predicted) with a reduced diffusing capacity for carbon monoxide (DLCO), and hypoxemia with hypocapnia. The mean (+/- SD) right atrial pressure was 9.7 +/- 6 mm Hg; mean pulmonary artery pressure, 60 +/- 18 mm Hg; cardiac index, 2.3 +/- 0.9 L/min X m2; and pulmonary vascular resistance index, 26 +/- 14 mm Hg/L/min X m2 for the group. Although no deaths or sustained morbid events occurred during the diagnostic evaluation of the patients, the typically long interval from initial symptoms to diagnosis emphasizes the need to develop strategies to make the diagnosis earlier.
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PMID:Primary pulmonary hypertension. A national prospective study. 360

To define the long-term natural history of congenital complete heart block, we followed 27 patients prospectively by means of frequent ambulatory electrocardiographic (ECG) recordings for a mean (+/- SD) of 8 +/- 3 years. During that time, 8 of the 13 patients with a mean daytime heart rate below 50 bpm (Group A) had cardiac complications such as sudden death, syncope, presyncope, or excessive fatigue. Six of the eight patients had additional ECG findings that suggested an instability of the junctional escape mechanism. These findings included nocturnal junctional exit block (three patients), little or no change in the junctional rate with physical activity (three patients), and associated tachyarrhythmias (three patients). None of the 14 patients with a mean daytime heart rate of 50 bpm or more (Group B) had an adverse clinical outcome, and 5 of the 13 patients in Group A also remained well. Among the five patients in stable condition in Group A, three had no evidence of an unstable junctional mechanism. We conclude that patients with a mean daytime junctional rate below 50 bpm and other evidence of an unstable junctional escape mechanism should probably undergo prophylactic pacemaker implantation. Since junctional exit block and tachyarrhythmias sometimes appear first during follow-up, the method of risk stratification employed in this study depends on serial ambulatory ECG recordings.
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PMID:Use of ambulatory electrocardiographic monitoring to identify high-risk patients with congenital complete heart block. 382 27

The clinical and electrophysiological features and the natural history of median intra-His block with a normal resting electrocardiogram were studied: 11 patients had a fixed split H1-H2 potential with a spontaneous or induced block between H1 and H2. The patients (5 men and 6 women) were aged 17 to 70 years (average 53 years). Associated pathology included 2 cases of aortic stenosis (1 severe), 1 case of ischaemic heart disease (effort angina), 1 case of mitral valve prolapse and 2 cases of hypertension. The presenting symptoms were syncope (4 cases), dizziness (2 cases), effort angina (1 case) and tiredness (3 cases); 1 patient was asymptomatic. Holter monitoring (24 hours) was performed in 8 patients and s-owed paroxysmal conduction defects in 6 cases; 4 Mobitz II 2nd degree AV block, 1 3rd degree AV block with narrow QRS complexes and 1 case of blocked atrial extrasystoles at coupling intervals longer than 480 ms and sinus cycle lengths of over 800 ms. Exercise testing by bicycle ergometry (4 patients) was normal in 1 case and revealed Mobitz II 2nd degree AV block in 3 cases. Baseline electrophysiological studies showed an A-H1 interval ranging from 60 to 100 ms (average 78 ms), a H1-H2 interval of 20 to 40 ms (average 31 ms) and a H2-V interval of 30 to 50 ms (average 32 ms). Block between H1 and H2 was observed: "spontaneously" during electrophysiological investigation in 6 cases, after IV atropine in 1 case, during overdrive atrial pacing at rates slower than 150/min in 7 cases, after atrial extrastimulus with a functional intra-His refractory period of over 420 ms in 7 cases, after ajmaline in 3 of the 4 cases in which this test was performed. A cardiac pacemaker was implanted in 10 patients in whom the initial symptoms have all regressed; the remaining patient considered to be "epileptic" had another syncopal attack under therapy and was finally paced. This series demonstrates that the diagnosis of median intra-His block depends on precise electrophysiological criteria and should be looked for even when the presenting symptoms are atypical; some of our patients complained only of tiredness. The value of Holter monitoring and careful endocavitary investigation is emphasised. Median intra-His block should be distinguished from longitudinal and functional His bundle dissociation.
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PMID:[Clinical and electrophysiological aspects of median intra-His bundle block with normal electrocardiogram at rest]. 392 29

We have reviewed the histories of 320 patients in whom a diagnosis of coronary heart disease was ultimately established and traced the symptoms back to their first appearance. In 51% the first symptom was effort angina. Difficulties in recognition arose when the symptom was localized to an unusual site, when its occurrence was dependent on a combination of exercise with cold or a recent meal, or when it was induced by excitement rather than by effort. In a quarter of the cases the onset of angina was abrupt, and in these there was usually evidence of acute infarction.In 43% of cases the first symptom was an attack of pain or discomfort in the torso occurring without any discernable precipitating factor. Again, diagnosis was difficult when the pain was in an atypical site and also when it was of brief duration associated with skeletal or abdominal disease which could cause pain at the same site, or if the patient was able to undertake strenuous exertion. In four patients cardiac pain was first experienced during a paroxysm of tachycardia. In 6% of cases the onset was marked by a symptom other than pain-most frequently dyspnoea, tiredness, faintness, or syncope.Clinical examination was of no direct value in diagnosis. Its importance lay in disclosing factors which had to be taken into account in interpreting the electrocardiogram. The electrocardiogram was invaluable, though by no means infallible. In over half of the patients the first tracing showed major abnormalities of coronary type, and nearly a quarter more showed minor S-T/T depression consistent with coronary disease. Ten per cent. showed miscellaneous abnormalities, such as left ventricular hypertrophy or bundle-branch block, and 15% no definite abnormality.There is as yet no completely reliable objective method of diagnosing early coronary heart disease, so that the recognition of symptoms remains of paramount importance.
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PMID:Earliest symptoms of coronary heart disease and their recognition. 502 16

Three patients with symptomatic sinus bradycardia due to sick sinus syndrome were treated with permanent ventricular pacing for periods ranging from 2.5 to 4 years. All three patients had ventriculo-atrial conduction on routine electrocardiography. Although ventricular pacing was effective, they complained of fatigue, lightheadedness, and near syncope. Hemodynamic studies revealed the presence of regular cannon waves in the right atrium as well as in the pulmonary artery wedge pressure curves. Temporary atrial pacing resulted in disappearance of the cannon waves and a significant rise in cardiac output (32-48%). After normal atrio-ventricular conduction was confirmed by rapid atrial stimulation and His bundle electrocardiography, the pacing mode was changed to permanent atrial pacing on demand. The effort tolerance of the patients markedly improved, and the previously mentioned symptoms disappeared. Control hemodynamic studies 9 to 12 months after implantation of the atrial demand pacemaker showed that the improvement in cardiac performance was maintained.
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PMID:Chronic ventricular pacing with ventriculo-atrial conduction versus atrial pacing in three patients with symptomatic sinus bradycardia. 617 83

In patients with aortic stenosis, delineation of the optimal timing of surgery is of particular importance since inappropriately early surgery subjects the patient to the risk of prosthetic heart valve disease for a longer time than is necessary (Figure 1) and inappropriately late surgery can result in prolonged untreated symptoms and irreversible myocardial changes or systemic complications. A valve orifice area less than 1.0 cm2 or less than 0.7 cm2/m2, respectively, is indicative of critical stenosis. The indication for surgery should be established mainly on the basis of compromise of the valve orifice area equal to or in excess of the latter. In young patients surgical intervention should be carried out as soon as a critical stenosis is documented. Aortic stenosis can lead to symptoms such as fatigue, dyspnea, chest pain or syncope which surgery can eliminate and the incidence of sudden death may exceed 10% per year in symptomatic patients and can approach 2% per year in asymptomatic patients. In the younger age group, since the surgery required is almost exclusively commissurotomy rather than valve replacement, the operative mortality is less than 2% and the patient is not subjected to prosthetic heart valve disease. In adult patients with symptomatic, documented critical aortic stenosis, surgery should not be delayed. The symptoms can be ameliorated through surgery. The prognosis without surgery is poor with a five-year survival rate less than 50%, while after aortic valve replacement survival at five years is approximately 75 to 80%.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Timing of surgical therapy for aortic valve stenosis. Goals of therapy. 651 Aug 75

The premenstrual symptom complex many women experience in a moderate to severe form can be divided into four subgroups. Because there is more than one syndrome and nervous tension is one of the most common symptoms, the term premenstrual tension syndromes (PMTS) is used. The most common subgroup, PMT-A, consists of premenstrual anxiety, irritability and nervous tension, sometimes expressed in behavior patterns detrimental to self, family and society. Elevated blood estrogen and low progesterone have been observed in this subgroup. Administration of vitamin B6 at doses of 200-800 mg/day reduces blood estrogen, increases progesterone and results in improved symptoms under double-blind conditions. Women in this subgroup consume an excessive amount of dairy products and refined sugar, and progesterone may be of value in them. The second-most-common subgroup, PMT-H, is associated with symptoms of water and salt retention, abdominal bloating, mastalgia and weight gain. The severe form of PMT-H is associated with elevated serum aldosterone. Vitamin B6 at high dosage suppresses aldosterone and results in diuresis and clinical improvement. Vitamin E helps the breast symptoms. Methylxanthines and nicotine should be curtailed and sodium limited to 3 gm/day. PMT-C is characterized by premenstrual craving for sweets, increased appetite and indulgence in eating refined sugar followed by palpitation, fatigue, fainting spells, headache and sometimes the shakes. PMT-C patients have increased carbohydrate tolerance and low red-cell magnesium. Adequate magnesium replacement results in improved glucose tolerance tests and decreased PMT-C symptoms. Deficiency of the prostaglandin PGE1 may also be involved in PMT-C. PMT-D is the least common but most dangerous because suicide is most frequent in this subgroup. The symptoms are depression, withdrawal, insomnia, forgetfulness and confusion. In ten PMT-D patients the mean blood estrogen was lower and the mean blood progesterone higher than normal during the midluteal phase. Elevated adrenal androgens are observed in some hirsute PMT-D patients. Two PMT-D patients with normal blood progesterone and estrogens had high lead levels in hair tissue and chronic lead intoxication. This subgroups needs careful medical attention when the symptoms are severe. Therapy should be individualized according to the results of the evaluation.
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PMID:Nutritional factors in the etiology of the premenstrual tension syndromes. 668 67

The clinicopathologic features of constrictive pericardial disease in 13 dogs were reviewed. The causes were infection (3 dogs), metallic foreign body (1 dog), and idiopathic (9 dogs). Owner complaints included abdominal enlargement, tachypnea, weakness or syncope, exertional fatigue, and weight loss. Ascites and jugular venous distention were consistently observed, whereas abnormalities of arterial pulses and heart sounds were variable and inconsistent. Diminished QRS voltages were common. Mild to moderate cardiomegaly, rounding of the cardiac silhouette, and variable and nonspecific angiographic findings were frequently observed. Cardiac catheterization consistently showed elevation and equilibration of atrial and ventricular diastolic pressures, but a prominent early diastolic (y) descent was uncommon. Fibrosis was confined to the parietal pericardium in 8 dogs, and included the epicardium in 5 dogs. Parietal pericardectomy was successful in relieving the syndrome in 6 of 10 dogs. Pulmonary thrombosis was the most common cause of early postoperative mortality.
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PMID:Constrictive pericardial disease in the dog. 670 98


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