The electrocardiogram during physical stress and Holter monitoring in the detection of asymptomatic myocardial infarct

INTRODUCTION: In patients with myocardial infarction acute myocardial ischaemia could be manifested by characteristic ischaemic symptoms or noncharacteristic symptoms such as cardiac insufficiency or heart rhythm disturbances. Sometimes myocardial ischaemia is not followed by any symptom. This condition is known as asymptomatic myocardial ischaemia. Asymptomatic myocardial ischaemia usually could be detected by treadmill exercise tolerance test or 24-hour Holter ECG monitoring. PATIENTS AND METHODS: We analyzed a group of 58 patients suffering from myocardial infarction with ST segment depression during the treadmill exercise tolerance test. All patients were on Holter 24-hour ECG monitoring. As a criterion of myocardial ischaemia during Holter monitoring ST segment depression of 1 mm and more, lasting 1 minute and more, and 0.08" of J point was accepted. RESULTS: During the treadmill exercise tolerance test segment depression was not followed by any symptom in 18 (31%) patients. There were no differences in the number of patients with hypertension in the group with symptoms and the group without symptoms. Diabetes mellitus was more frequent in the group with asymptomatic myocardial ischaemia. The average values of maximum ST segment depression and heart rates during treadmill tests were not statistically significant in both groups (with and without symptoms). During daily activities myocardial ischaemia was found in 30 (51%) patients by a 24-hour Holter ECG monitoring. We observed 198 episodes of myocardial ischaemia of which 138 (69.1%) were asymtomatic. The amplitude of ST segment depression and duration of these changes were significantly greater in the group with symptomatic episodes than in the group with asymptomatic episodes of myocardial ischaemia. DISCUSSION: Asymptomatic myocardial ischaemia is an often appearance in patients with myocardial ischaemia. Almost in 25% of persons in whom sudden death occurred obstructive changes in coronary arteries during the autopsy were found. Asymptomatic myocardial ischaemia could be found even an a "completely healthy person" without any complaints. Asymptomatic myocardial ischaemia is usually detected in a "completely healthy person" by casual diagnosis, in patients with stable and non stable angina pectoris, in patients with stenosis of the coronary arteries proved by angiography, and in patients after myocardial infarction. Some authors considered that treadmill exercise tolerance testing is less reliable to discover asymptomatic myocardial ischaemia comparing to the continuous 24-hour Holter ECG monitoring. It is know that in patients with diabetes mellitus neuropathy precedes the onset of symptomatic myocardial ischaemia. Asymptomatic myocardial ischaemia has the same predictive value for prognosis of the disease as symptomatic myocardial ischaemia. In some patients "anginal alarm system" is defective, and perception and conduction of pain sensations are disturbed. CONCLUSION: 1. In 31% of patients who suffered from myocardial infarction with ST segment depression during the treadmill testing asymptomatic myocardial ischaemia was found. 2. By Holter monitoring ischaemia ST segment depression during the exertion is observed in 52% of patients. Most of ischaemic episodes were asymptomatic. 3. The amplitude of ST segment depression is significantly greater and duration of depression is significantly longer in symptomatic episodes of myocardial ischaemia comparing to asymptomatic myocardial ischaemia obtained by Holter ECG monitoring.     

Prediction of the helix/strand content of globular proteins based on their primary sequences

Population screening for hemochromatosis done by using the transferrin saturation test has been advocated by experts to permit the initiation of therapeutic phlebotomy before the onset of clinical disease. The discovery of a gene associated with hemochromatosis has made DNA testing another option for screening and diagnosis. In this paper, U.S. Preventive Services Task Force criteria are used to evaluate the evidence for the usefulness of population screening done by using iron measures or genetic testing. Published clinical research offers little evidence to suggest that population screening for hemochromatosis done by using genetic testing improves clinical outcomes. Although one recently discovered mutation, C282Y, accounts for 60% to 92% of cases of the disease in series of patients with hemochromatosis, uncertainties remain about the clinical penetrance of various genotypes; the accuracy of genetic testing; and the ethical, legal, and social effects of genetic testing. Before population screening for hemochromatosis done by using transferrin saturation testing can be recommended, laboratory standardization needs to be addressed and questions about risk for clinical disease in asymptomatic persons with mutations or early biochemical expression of disease require resolution. Evidence from case series suggests that hemochromatosis may be associated with liver cancer, other liver disease, diabetes, bradyarrhythmias, and arthritis. In all studies but one, however, estimation of the magnitude and significance of this risk is limited by lack of adequate comparison groups. The need for population data to answer questions about penetrance among asymptomatic persons should not impede efforts to increase the detection and treatment of hemochromatosis in persons found to have elevated iron measures a family history of hemochromatosis, or consistent early signs and symptoms of the disease.     

"Childhood" viruses as a cause of pneumonia in adults

Respiratory viruses are a common cause of morbidity in childhood. Except in the child with immunodeficiency, the common respiratory viruses rarely pose a serious threat to life. Because infection with most of these viruses in childhood is nearly universal and usually bestows partial immunity, the "childhood respiratory viruses" are not generally thought of as being a cause of disease in adults. However, adults who work around children, who are frequently exposed to other adults and children with respiratory tract infections (as in a hospital clinic setting), or who are military recruits appear to be at risk of infection or reinfection with one of these agents. In addition, adults with immune deficiency are at a significant risk for serious infection. The risk of serious disease can be reduced by maximizing immunity with (re)immunization and optimal treatment of any underlying disorders. Tobacco smoke and respiratory irritants should be avoided and adults at risk for severe disease should avoid contact with infected children and adults as much as possible. Specific chemotherapy for viral pneumonia, when available, may reduce morbidity in selected individuals.     

Sexual functioning in ambulatory men with HIV/AIDS

Sexual functioning is often neglected in the care of HIV-infected patients. Little information exists about the relationship between hormonal factors, psychological factors, medication, HIV disease stage and sexual functioning among persons with HIV disease. In this study, 50 HIV+ men completed the Derogatis Sexual Functioning Inventory (DSFI), and had serum hormonal assays drawn (testosterone, thyroid function test, leuteinizing hormone, prolactin and oestradiol). Although all the subjects reported some degree of sexual dysfunction, persons with symptomatic HIV/AIDS reported more negative mood, lower sexual satisfaction scores and worse body image than persons with asymptomatic HIV. Persons with asymptomatic HIV also tended to have normal testosterone levels compared with persons with symptomatic HIV/AIDS. No relationship was found between medications and low testosterone, although numbers were small. These results suggest that sexual dysfunction is prevalent among persons with HIV disease, is more common as patients become symptomatic and progress to AIDS and that both physiological (low testosterone) and psychological issues play a role.     

Meeting the challenge of early identification of HIV infection in primary care

The authors review the role of human immunodeficiency virus (HIV) testing in primary care, including an overview of epidemiologic trends of the HIV epidemic; avenues for HIV counseling and testing; HIV testing assays; guidelines for HIV test counseling in primary care; special situations involving testing of pregnant women, infants, and young children; post-exposure prophylaxis; and related resources available to Wisconsin primary care clinicians. HIV disease is a major cause of premature death and disability in the United States. Advances in the understanding of the pathogenesis of HIV and developments of newer antiretroviral therapies have resulted in dramatic changes in the management of HIV disease. Combination antiretroviral drug therapy has resulted in prolonged and near complete suppression of detectable HIV replication in many HIV-infected persons. These clinical developments underscore the importance of early identification and intervention in HIV disease. Intervention during primary HIV infection, the time when the viral burden "set point" is achieved, may present a special window of opportunity to effectively intervene in limiting viral replication in an infected individual. This earliest intervention may have major benefits for infected persons and society at large. Decreasing viral load during primary HIV infection may decrease an individual's infectiousness and thereby decrease the overall rate of transmission of infection to others. Primary care clinicians play a critical role in diagnosing, managing, and preventing HIV infection. Because of the ongoing relationship between patient and health care provider, the primary health care clinician is in the best position to provide HIV risk assessment, testing, related prevention education, and coordination of needed health care. This article presents guidelines for conducting HIV counseling and testing in primary care for purposes of furthering the public health objective of early identification of HIV infection. Clinicians can achieve this objective by including HIV risk assessment during the initial history and physical exam of every patient.     

Diagnosis and classification of diabetes mellitus: new criteria

New recommendations for the classification and diagnosis of diabetes mellitus include the preferred use of the terms "type 1" and "type 2" instead of "IDDM" and "NIDDM" to designate the two major types of diabetes mellitus; simplification of the diagnostic criteria for diabetes mellitus to two abnormal fasting plasma determinations; and a lower cutoff for fasting plasma glucose (126 mg per dL [7 mmol per L] or higher) to confirm the diagnosis of diabetes mellitus. These changes provide an easier and more reliable means of diagnosing persons at risk of complications from hyperglycemia. Currently, only one half of the people who have diabetes mellitus have been diagnosed. Screening for diabetes mellitus should begin at 45 years of age and should be repeated every three years in persons without risk factors, and should begin earlier and be repeated more often in those with risk factors. Risk factors include obesity, first-degree relatives with diabetes mellitus, hypertension, hypertriglyceridemia or previous evidence of impaired glucose homeostasis. Earlier detection of diabetes mellitus may lead to tighter control of blood glucose levels and a reduction in the severity of complications associated with this disease.     

Graded functional activation in the visuospatial system with the amount of task demand

Immunocompromised hosts have defects in their immune system that make them at risk of developing a variety of infections. In addition, these persons may develop a wide variety of noninfectious disease processes that involve the lung. These disorders may be caused by the underlying disease process. This may be seen with the development of metastatic disease from the underlying neoplasm, or it may represent the development of a malignancy secondary to therapy, as is seen with posttransplant lymphoproliferative disease. The abnormalities may be a result of the therapy used to treat the patients, as is seen with radiation injury to the lung and drug toxicity. Pulmonary edema may occur and be from a wide variety of causes. All of these disease processes may simulate an infectious process and must be differentiated from infection to allow proper therapeutic intervention.     

Triphenyltin acetate toxicity: a biochemical and ultrastructural study on mouse thymocytes

Eighty-five subjects at various stages of human immunodeficiency virus (HIV-1) infection and 39 seronegative controls underwent neurological and neuropsychological evaluation to assess the relationship between cognitive test results and subjective complaints (cognitive, affective, motor, and other). The effect of psychiatric disorders on the association between cognitive performance and complaints of the patients was also examined. Patients with symptomatic infection had higher frequency of complaints than subjects at asymptomatic stage. Detailed neuropsychological examination confirmed a strong association between poor verbal memory and cognitive complaints. Poor performance on cognitive speed and flexibility was associated with motor complaints and motor abnormalities. These associations were not explained by psychiatric disorders or elevated depression questionnaire scores. Our observations indicate that, especially in symptomatic HIV-1 infection cognitive changes reported by patients often reflect "objective" cognitive decline, and may be the earliest signs of HIV-1 associated cognitive disorder. No direct relationship was observed between "subjective" complaints and neuropsychological performance of asymptomatic subjects. Understanding the significance of reported cognitive changes have important therapeutic implications.     

On the use of the ratio or the odds ratio of cure rates in therapeutic equivalence clinical trials with binary endpoints

Acutely ill patients who are immunocompromised but not neutropenic most commonly are: (1) diabetic; (2) on chronic high-dose steroid therapy; (3) have lupus; or (4) have impaired or absent splenic function. These patients often present in the CCU because of the severity of their infection. Differential diagnosis may be approached by first considering the patient's underlying disease, i.e., SLE. The next step in the diagnostic process is to appreciate the immune defect associated with these disorders. The nature of the immune defect determines which clinical pathogens are related to the immune defect. Pathogens are associated with a sterotyped pattern of organ involvement. The object of the diagnostic analysis is to determine the most likely organism affecting a particular organ system, given the defect in host defenses associated with the patient's underlying illness. In this way, a useful clinical diagnosis can be made rapidly, and appropriate clinical specimens obtained for diagnostic testing. Often empiric therapy must be started pending the results of diagnostic testing. In such situations, empiric therapy ordinarily is directed against the bacterial pathogens most likely to cause disease relevant to the patient's impaired defenses. Specific therapy for unusual or exotic pathogens should not be empiric and should be based on demonstration of a pathogenic role by the microorganism. In the case of miliary tuberculosis or invasive fungal disease, a case may be made for early empiric therapy to cover these organisms if there is sufficient clinical suspicion based on the presenting signs and symptoms as well as the pattern of organ involvement. As with all infections, but particularly in immunocompromised patients, the early initiation of appropriate antimicrobial therapy is essential and often life-saving.     

Cough. A comprehensive review

An understanding of the anatomic, physiologic, and pathophysiologic aspects of cough is necessary to appropriately diagnose and treat patients with cough. In the majority of persons, cough that is acute and self-limiting is usually secondary to a viral upper respiratory tract infection; cough that is chronic and persistent is usually due to chronic bronchitis or postnasal drip. In the remaining persons, to determine the cause of cough, it is necessary to systematically consider anatomic locations were receptors and afferent nervous pathways are located. Definitive treatment of cough depends on determining its precise cause and then initiating specific therapy for the underlying disorder. Only when the cause of cough remains unknown or when cough performs no useful function and its complications represent a potential hazard to the patient, should symptomatic treatment be considered. Combination cough preparations should not be prescribed.     

Primary hyperparathyroidism

Primary hyperparathyroidism is not rare. It is particularly common after the age of 50 and may affect up to 3% of postmenopausal women. It is commonly found as a result of blood tests performed for other reasons and is therefore often asymptomatic. Surgical treatment is recommended for patients with renal stone disease, plasma calcium above 3 mmol/L and accelerated bone loss (e.g., bone density < 3 standard deviations below the young normal mean). There is considerable debate about whether mild asymptomatic disease should be treated, but if there is rapid bone loss, either surgical or medical therapy with hormones or bisphosphonates is indicated.     

Imaging and radiologic management of upper urinary tract infections

Most infections of the upper urinary tract respond promptly to antibiotic therapy and imaging is not necessary. Patients with urinary obstruction, diabetes, or immunocompromise are more likely to develop complicated infection, abscess, or have unusual organisms. Chronic granulomatous processes involving the kidney are usually related to recurrent bacterial infections. Again, stone disease or obstruction is often an underlying problem. In those patients who do not respond promptly to treatment or have a more complicated clinical picture, imaging can assess the severity and extent of disease. CT scan is the study of choice for diagnostic evaluation in these patients and directs percutaneous intervention when appropriate. Placement of drainage catheters is often curative but also may allow the patient to stabilize until surgical treatment is accomplished. One exception is the diagnosis of pyonephrosis, which may be accomplished more easily by ultrasound. In these cases, PCN placement is generally needed and is performed under fluoroscopic guidance. Ultimately, however, definitive surgical intervention often is needed to relieve the underlying obstruction.     

The psychological and perceptual-motor aspects of Huntington's disease.

Reviews research regarding the psychological and perceptual-motor aspects of Huntington's disease (HD), arguing that (1) more effort should be taken to explore and understand the nature of the underlying psychological processes contributing to the motor disorder, an aspect of the disease neglected by researchers, and (2) a more positive strategy should be used when research is designed to enhance psychomotor performance. A model describing the perceptual-motor mechanisms that may be operating in persons with HD is proposed. The model is based on the notion that rehabilitative methods designed to improve the quality of the internal kinesthetic (i.e., proprioceptive) feedback signals generated from movements may improve motor control and thereby reduce the extent and/or the rate of the decline in motor skills. It is contended that such a program of research may provide a broader understanding of the underlying processes that affect motor behavior and yield methods designed to improve the control of movement. Implications of the model for stress and anxiety, short-term memory deficits, and motor learning are discussed. (48 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pityriasis rotunda

Pityriasis rotunda is an uncommon cutaneous disorder consisting of asymptomatic, strikingly circular, scaly lesions on the trunk and extremities, with the histologic appearance of ichthyosis vulgaris. Previous cases have been described in Japanese, South African, and West Indian persons, usually in association with an underlying serious systemic disease. A case of pityriasis rotunda in a 32-year-old black man in whom no diagnosable disorder could be demonstrated is presented.     

Disseminated acanthamoeba infection in patients with AIDS: case reports and review

Acanthamoeba infection has been described as an opportunistic infection in persons with AIDS. We report two cases of patients with AIDS and acanthamoeba infection and review the manifestations of this protozoan infection in patients infected with human immunodeficiency virus. The diagnosis of this infection requires a high index of suspicion because the clinical and histologic manifestations may be confused with those of disseminated fungal or algal disease. Clinicians and laboratory personnel should be aware of this potentially fatal condition so that appropriate diagnostic studies can be performed and treatment can be urgently administered. Early initiation of therapy may alter the clinical outcome of the disease.     

Environmental-medical diagnosis and therapy. Hasty diagnosis of unspecified environmental syndromes should be avoided

In the past ten years environmental medicine has virtually exploded. Major instruments for the interdisciplinary environmental-medical diagnosis are history, on-site inspection, biomonitoring and ambient monitoring. Since the definitive diagnosis of an environment-related disease usually requires a joint evaluation of toxicological, somatic and psychosomatic findings, it is recommended that cooperation with an experienced center for environment medicine should be established early on. By doing so, an inappropriate diagnosis of unspecific environment-medical symptom complexes such as, e.g., multiple chemical sensitivity may be avoided. Such "diagnoses" may result in drastic, and for the patient and his family, often stressful, consequences.     

Anti-malignin antibody evaluation: a possible challenge for cancer management

The major problem in the management of cancer is the difficulty of an early diagnosis. Clinical signs and symptoms generally appear late in the course of the disease. The availability of a non-invasive test which detects a blood molecule closely associated with the malignant transformation of the cells could be of help in the early detection of cancer. Malignin is a 10 kDa polypeptide located in the cytoplasmic and outer membranes of all malignant cells. Anti-malignin antibodies (AMAs) are IgM immunoglobulins spontaneously produced by the host against the oncoprotein malignin when neoplastic transformation occurs; since AMAs are IgM, they can represent an "early" transformation indicator useful for the early detection of cancer. Elevated AMA serum concentrations, measured by means of TARGET@ reagent, have been demonstrated in patients with a wide spectrum of non-terminal active cancers, regardless of the anatomical site and histotype of the tumor. The AMA test showed a sensitivity and specificity of 95% on first determination and > 99% on repeated determinations, and has been reported to be a promising diagnostic tool for the early detection of cancer, as well as for monitoring of the response to treatment and possibly for screening of an asymptomatic population.     

The asymptomatic HB6-Ag carrier: auto- and heterologous perils

The asympatomatic carrier--usually discovered on offering to be a blood donor--presents a complex health problem which to date has received only "guarded" attention. These carriers may be dangerous, because they can transmit the HBs-Ag not only by parenteral but also by "nonparenteral" means, due to its presence in urine, feces, saliva, tears, semen, vaginal discharge, menstrual flow, breast milk, joint, ascitic and cerebrospinal fluids. The transmission by sexual contact is well established. Inapparent transmission may also occur from insufficient sterilization of instruments, by tatooing, ear piercing, by barbers, manicurists, dentists and by mosquitoes and bedbugs. Some of the characteristics of an asymptomatic HBs-Ag carrier seem to be: a young male, most often black, from a poor social and hygienic environment with a possible gene dependent immune deficiency state. Our experiences suggest that all newly admitted patients to the hospital personnel should have determinations of the presence of HBs-Ag in their blood, so that adequate steps can be taken to protect their contacts from infection.     

Use of the Sugar Pill by Industrial Psychologists.

Argues that it is necessary, for the good of industrial psychology, that the Barnum Effect be discredited as a method for the validation of psychological tests. as a method for the validation of psychological tests. Businessmen, as they become aware of its nature and obvious limitations, should demand sophisticated methods of test validation. In order to avoid ills resulting from the "quick cure," businessmen should, at the same time, exercise a degree of patience in their demand for the services of psychologists. It should be up to businessmen to seek objective validity which goes far beyond mere anecdotal accounts. Decisions based on psychological tests should be delayed until good evidence of the tests' validity is presented. At the same time, it is the ethical duty of industrial psychologists to resist the temptation to use tests which have not been properly validated. It is their duty to educate the persons for whom they perform services; further, it is their duty to create and maintain an atmosphere conducive to test research and validation. In many cases, they will need to "unsell" more persons on testing than they will be called upon to sell, and they will need to caution their clients concerning the many qualifications to be attached to test interpretations. methods of appropriate psychological test validation. By demanding a high level of competency from industrial and consulting psychologists, American business will render unprofitable the currently widespread use of questionable and often misguided psychological test appraisals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)