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STUDY DESIGN: Case reports describing abdominal complications following percutaneous enteral gastric (PEG) tube placement in three tetraplegics. OBJECTIVES: The aim was to increase provider awareness of PEG tube dislodgement as a complication in tetraplegics. SETTING: Spinal cord injury center, Veteran's Administration hospital. METHODS: The charts of three spinal cord injured veterans with tetraplegia were reviewed for clinical presentation and radiographic findings supporting the diagnosis of acute abdominal complications following PEG tube dislodgement. RESULTS: PEG tube dislodgement in tetraplegics can present with occult findings and lead to disastrous outcomes if the diagnosis is delayed. CONCLUSION: PEG tube dislodgement should be considered in tetraplegics who develop even subtle abdominal complaints, especially if the injury is complete. Further assessment with computed tomography (CT) scans or fistulograms should be considered to help with decision making.
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Traumatismos Abdominales/etiología , Nutrición Enteral/efectos adversos , Intubación Gastrointestinal/efectos adversos , Cuadriplejía/enfermería , Administración Cutánea , Adulto , Anciano de 80 o más Años , Humanos , Masculino , Tomógrafos Computarizados por Rayos X , VeteranosRESUMEN
STUDY DESIGN: Randomized, double blind, placebo-controlled trial with a crossover design. OBJECTIVE: To evaluate cranberry tablets for the prevention of urinary tract infection (UTI) in spinal cord injured (SCI) patients. SETTING: Spinal Cord Injury Unit of a Veterans Administration Hospital, MA, USA. METHODS: Subjects with spinal cord injury and documentation of neurogenic bladder were randomized to receive 6 months of cranberry extract tablet or placebo, followed by the alternate preparation for an additional 6 months. The primary outcome was the incidence of UTI. RESULTS: Forty-seven subjects completed the trial. We found a reduction in the likelihood of UTI and symptoms for any month while receiving the cranberry tablet (P<0.05 for all). During the cranberry period, 6 subjects had 7 UTI, compared with 16 subjects and 21 UTI in the placebo period (P<0.05 for both number of subjects and incidence). The frequency of UTI was reduced to 0.3 UTI per year vs 1.0 UTI per year while receiving placebo. Subjects with a glomerular filtration rate (GFR) greater than 75 ml min(-1) received the most benefit. CONCLUSION: Cranberry extract tablets should be considered for the prevention of UTI in SCI patients with neurogenic bladder. Patients with a high GFR may receive the most benefit. SPONSORSHIP: Spinal Cord Research Foundation, sponsored by the Paralyzed Veterans of America.
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Extractos Vegetales/administración & dosificación , Traumatismos de la Médula Espinal/complicaciones , Vejiga Urinaria Neurogénica/complicaciones , Infecciones Urinarias/tratamiento farmacológico , Infecciones Urinarias/etiología , Vaccinium macrocarpon , Adulto , Anciano , Estudios Cruzados , Método Doble Ciego , Tasa de Filtración Glomerular/efectos de los fármacos , Tasa de Filtración Glomerular/fisiología , Humanos , Concentración de Iones de Hidrógeno/efectos de los fármacos , Masculino , Persona de Mediana Edad , Placebos , Proantocianidinas/farmacología , Proantocianidinas/uso terapéutico , Resultado del Tratamiento , Infecciones Urinarias/microbiología , Orina/química , Orina/microbiología , Urotelio/efectos de los fármacos , Urotelio/fisiologíaRESUMEN
STUDY DESIGN: Case report. OBJECTIVE: To describe an unusual case of progressive pulmonary hypertension due to recurrent pulmonary embolism in a chronically paralyzed spinal cord injury patient. SETTING: Veterans Administration Hospital, West Roxbury, MA, USA. SUBJECT: A 57-year-old man, tetraplegic, sensory incomplete and motor complete for 30 years due to a diving accident, complained of lightheadedness and shortness of breath intermittently for 7 years. Examination during the latest episode revealed anxiety, confusion, respirations 28 per min, blood pressure 80/60 mmHg, and arterial pH 7.41, P(CO2) 28 mmHg, P(O2) 95 mmHg on 2 l of oxygen. A chest film 2 weeks earlier had revealed a right-sided cutoff of pulmonary vasculature; the current film showed right-sided pleural effusion. Review of EKGs showed a trend of increasing right axis deviation with recovery and recurrences during the previous 9 years and a current incomplete right bundle branch block with clockwise rotation and inverted T waves in V1-4. Computerized tomography with contrast material revealed small pulmonary emboli, but only in retrospect. The patient died shortly after scanning. AUTOPSY: The pulmonary arteries were free of thromboemboli on gross examination but medium and small-sized arteries were constricted or obliterated with thrombotic material microscopically. The estimated ages of the thromboemboli ranged from days to years. The right ventricle was hypertrophied; the coronary arteries were patent. CONCLUSION: Recurrent pulmonary emboli resulted in chronic pulmonary hypertension and eventual death in a patient with chronic tetraplegia.
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Hipertensión Pulmonar/etiología , Embolia Pulmonar/etiología , Cuadriplejía/complicaciones , Enfermedad Crónica , Electrocardiografía/métodos , Humanos , Hipertensión Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar/patología , Masculino , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/patología , Radiografía , RecurrenciaRESUMEN
OBJECTIVE: To investigate the long-term effects of shunting on neurologic outcome of syringomyelia, a complication of spinal cord injury (SCI). DESIGN: Retrospective data collection using telephonic survey. SETTING: University based medical center. PARTICIPANTS: Eight of 15 patients who had shunts placed between 1976 and 1999. INTERVENTIONS: Review of clinical records and self-reported telephone interview. MAIN OUTCOMES MEASURES: Initial clinical presentation, recovery after shunt placement, and subsequent neurologic status were recorded. Patients were asked to rate symptomatic improvement after surgery on a 100-point analog scale; they were also asked whether they would have the surgery again. RESULTS: Presenting symptoms were weakness in all 8 patients, pain in 5 patients, and numbness in 5 patients. After shunting, 6 patients had improved strength, all had less pain, and 2 had less numbness. Six patients experienced neurologic decline an average of 2 years after shunt placement, 3 because of shunt failure, 2 from a new syrinx, and 1 from both shunt failure and new syrinx. Two of the 3 patients who underwent second shunt placements for a new syrinx had full neurologic recovery. Six patients said they would repeat the shunting procedure if necessary, 1 was uncertain, and 1 would not. CONCLUSION: Initial improvements noted after shunting provide long-lasting effects, even though many patients may need a second procedure. Less pain and improved strength are more significant than decreased numbness.
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Derivaciones del Líquido Cefalorraquídeo , Traumatismos de la Médula Espinal/complicaciones , Siringomielia/etiología , Siringomielia/cirugía , Humanos , Imagen por Resonancia Magnética , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Diffuse coronary atherosclerosis is the substrate for plaque rupture and coronary events. Therefore, in patients with mild arteriographic coronary artery disease without significant segmental dipyridamole-induced myocardial perfusion defects, we tested the hypothesis that fluid dynamically significant diffuse coronary artery narrowing is frequently manifest as a graded, longitudinal, base-to-apex myocardial perfusion abnormality by noninvasive PET. METHODS AND RESULTS: In this study, 1001 patients with documented coronary artery disease by coronary arteriography showing any visible coronary artery narrowing underwent rest-dipyridamole PET perfusion imaging. Quantitative severity of dipyridamole-induced, circumscribed, segmental PET perfusion defects was objectively measured by automated software as the minimum quadrant average relative activity indicating localized flow limiting stenoses. Quantitative severity of the graded, longitudinal, base-to-apex myocardial perfusion gradient indicating fluid dynamic effects of diffuse coronary artery narrowing was objectively measured by automated software as the spatial slope of relative activity along the cardiac longitudinal axis. CONCLUSIONS: In patients with mild arteriographic disease without statistically significant dipyridamole-induced segmental myocardial perfusion defects caused by flow-limiting stenoses compared with normal control subjects, there was a graded, longitudinal, base-to-apex myocardial perfusion gradient significantly different from normal control subjects (P=0. 001) that was also observed for moderate to severe dipyridamole-induced segmental perfusion defects (P=0.0001), indicating diffuse disease underlying segmental perfusion defects; 43% of patients with or without segmental perfusion defects demonstrated graded, longitudinal, base-to-apex perfusion abnormalities beyond +/-2 SD of normal control subjects, indicating diffuse coronary arterial narrowing by noninvasive PET perfusion imaging.
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Enfermedad Coronaria/diagnóstico por imagen , Enfermedad Coronaria/fisiopatología , Vasos Coronarios/fisiología , Tomografía Computarizada de Emisión/métodos , Adulto , Anciano , Anciano de 80 o más Años , Arteriosclerosis/diagnóstico por imagen , Arteriosclerosis/fisiopatología , Dipiridamol , Humanos , Estudios Longitudinales , Persona de Mediana Edad , Contracción Miocárdica/efectos de los fármacos , Contracción Miocárdica/fisiología , Índice de Severidad de la Enfermedad , VasodilatadoresRESUMEN
OBJECTIVE: To quantify changes in size and severity of myocardial perfusion abnormalities by positron emission tomography (PET) in patients with coronary artery disease after 5 years of risk factor modification. DESIGN: Randomized controlled trial. SETTING: Outpatient community setting. INTERVENTION: Randomization of patients to risk factor modification consisting of very low-fat vegetarian diet, mild to moderate exercise, stress management, and group support (experimental group, n = 20) or to usual care by their own physicians, consisting principally of antianginal therapy (control group, n = 15). MAIN OUTCOME MEASURES: Quantitative coronary arteriography and PET at baseline and 5 years after randomization. Automated, objective measures of size and severity of perfusion abnormalities on rest-dipyridamole PET images and of stenosis severity on arteriograms were made by computer algorithms. RESULTS: Size and severity of perfusion abnormalities on dipyridamole PET images decreased (improved) after risk factor modification in the experimental group compared with an increase (worsening) of size and severity in controls. The percentage of left ventricle perfusion abnormalities outside 2.5 SDs of those of normal persons (based on 20 disease-free individuals) on the dipyridamole PET image of normalized counts worsened in controls (mean +/- SE, + 10.3% +/- 5.6%) and improved in the experimental group (mean +/- SE, -5.1% +/- 4.8%) (P = .02); the percentage of left ventricle with activity less than 60% of the maximum activity on the dipyridamole PET image of normalized counts worsened in controls (+13.5% +/- 3.8%) and improved in the experimental group (-4.2% +/- 3.8%) (P = .002); and the myocardial quadrant on the PET image with the lowest average activity expressed as a percentage of maximum activity worsened in controls (-8.8% +/- 2.3%) and improved in the experimental group (+4.9% +/- 3.3%) (P = .001). The size and severity of perfusion abnormalities on resting PET images were also significantly improved in the experimental group as compared with controls. The relative magnitude of changes in size and severity of PET perfusion abnormalities was comparable to or greater than the magnitude of changes in percent diameter stenosis, absolute stenosis lumen area, or stenosis flow reserve documented by quantitative coronary arteriography. CONCLUSIONS: Modest regression of coronary artery stenoses after risk factor modification is associated with decreased size and severity of perfusion abnormalities on rest-dipyridamole PET images. Progression or regression of coronary artery disease can be followed noninvasively by dipyridamole PET reflecting the integrated flow capacity of the entire coronary arterial circulation.
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Terapia Combinada , Enfermedad Coronaria/diagnóstico por imagen , Enfermedad Coronaria/terapia , Vasos Coronarios/diagnóstico por imagen , Adulto , Anciano , Terapia Conductista , Angiografía Coronaria , Dieta con Restricción de Grasas , Dieta Vegetariana , Ejercicio Físico , Prueba de Esfuerzo , Femenino , Humanos , Hipolipemiantes/uso terapéutico , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Factores de Riesgo , Grupos de Autoayuda , Estrés Fisiológico/terapia , Tomografía Computarizada de EmisiónRESUMEN
BACKGROUND: Cholesterol lowering over 1- to 3-year trials is associated with modest regression or no progression of focal coronary artery stenoses compared with progression in controls, a decrease in cardiac events proportionately more than the modest improvement in percent stenosis, and in experimental animals improved endothelial-mediated coronary vasodilation. METHODS AND RESULTS: Accordingly, we hypothesized that there would be improvement in size and severity of perfusion abnormalities by rest-dipyridamole positron emission tomography (PET) imaging in a randomized intensive cholesterol-lowering trial with each patient studied after a baseline control period, a 90-day intensive cholesterol-lowering treatment, and a final control period off cholesterol-lowering regimens. Completely automated, objective measures of size and severity of perfusion abnormalities on rest-dipyridamole PET images were made by computer algorithm in 12 patients with coronary artery disease. There were statistically significant decreases (improvement) in size and severity of perfusion abnormalities by rest-dipyridamole PET on comparison of baseline control with perfusion abnormalities after intensive 90-day cholesterol lowering and significant increases (worsening) in size and severity after the final control period, respectively, as follows. (1) The percent of left ventricle outside 2.5 SD of normal values on the dipyridamole-to-rest ratio image of normalized counts was 22 +/- 20% after the initial control period, 13 +/- 14% after the treatment period, and 26 +/- 22% after the final control period with a significant decrease (improvement) occurring between the initial control and treatment periods (P = .02) and an increase (worsening) occurring between the treatment and final control periods (P = .009). (2) The percent of left ventricle with a ratio of < or = 0.66 in the dipyridamole-to-rest ratio image of normalized counts was 11 +/- 13% after the initial control period, 5.8 +/- 10% after the treatment period, and 14 +/- 19% after the final control period with a significant decrease (improvement) occurring between the initial control and treatment periods (P = .04) and an increase (worsening) occurring between the treatment and final control periods (P = .02). (3) The myocardial quadrant on the polar display with the lowest average activity expressed as a percent of maximal activity was 0.81 +/- 0.18 after the initial control period, 0.87 +/- 0.014 after the treatment period, and 0.77 +/- 0.23 after the final control period with significant improvement occurring between the initial control and treatment periods (P = .05) and worsening occurring between the treatment and final control periods (P = .05). CONCLUSIONS: These results suggest that relatively short-term, intensive cholesterol lowering over 90 days improves myocardial perfusion capacity before anatomic regression of stenoses occurs and that such improvement, or deterioration after withdrawal of lipid-lowering treatment, can be followed noninvasively by dipyridamole PET, reflecting the integrated flow capacity of the entire coronary arterial/arteriolar vascular system affected by diffuse atherosclerosis.
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Colesterol/sangre , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Dipiridamol , Corazón/diagnóstico por imagen , Tomografía Computarizada de Emisión , Adulto , Colesterol en la Dieta/administración & dosificación , Resina de Colestiramina/administración & dosificación , Enfermedad de la Arteria Coronaria/terapia , Grasas de la Dieta/administración & dosificación , Femenino , Alimentos Formulados , Humanos , Procesamiento de Imagen Asistido por Computador , Lovastatina/uso terapéutico , Masculino , Nutrición Parenteral Total , Factores de TiempoRESUMEN
OBJECTIVES: The purpose of this study was to test the hypothesis that transvalvular left ventricular assistance would support the circulation in patients with cardiogenic shock secondary to acute myocardial infarction and allow recovery of function in patients with a reversibly damaged (stunned) left ventricle. BACKGROUND: Cardiogenic shock occurs in 7.5% of patients presenting with acute myocardial infarction, resulting in survival of only 20%. Despite the use of aggressive interventional therapy in patients with shock secondary to anterior myocardial infarction, survival remains as low as 33%. METHODS: We studied 11 patients with acute myocardial infarction and cardiogenic shock, as defined by a cardiac index < 2 liters/min per m2, pulmonary capillary wedge pressure > 18 mm Hg and systolic blood pressure < 90 mm Hg during positive inotropic therapy. Patients were 57 +/- 13 years old (mean +/- SD) and had a mean left ventricular ejection fraction of 25 +/- 11%, mean arterial pressure of 69 +/- 13 mm Hg and mean cardiac index of 1.6 +/- 0.4 liters/min per m2 on admission to the study. RESULTS: During the 1st 24 h of left ventricular assistance, pulmonary capillary wedge pressure decreased from 26 +/- 4 to 16 +/- 4 mm Hg (p = 0.01), cardiac index increased from 1.6 +/- 0.4 to 2.4 +/- 0.4 liters/min per m2, and the dopamine hydrochloride dose decreased from 51 +/- 92 to 18 +/- 12 micrograms/kg body weight per min. In survivors, cardiac index improved to 3.2 +/- 0.5 liters/min per m2 (p = 0.01), and left ventricular ejection fraction improved to 34 +/- 5% (p < 0.05). The overall survival in the study group was 4 (36%) of 11 patients (95% confidence interval [CI] 8% to 65%), and 4 (66%) of 6 patients (95% CI 29% to 100%) with a Q wave anterior myocardial infarction survived. CONCLUSIONS: Transvalvular left ventricular support during cardiogenic shock complicating acute myocardial infarction is feasible and results in significant hemodynamic and functional improvement.
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Corazón Auxiliar , Hemodinámica/fisiología , Infarto del Miocardio/complicaciones , Aturdimiento Miocárdico/terapia , Choque Cardiogénico/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Aturdimiento Miocárdico/fisiopatología , Proyectos Piloto , Choque Cardiogénico/etiología , Choque Cardiogénico/mortalidad , Tasa de Supervivencia , Factores de TiempoRESUMEN
Percutaneous aortic and mitral valvuloplasty are recognized as alternative interventions in cases of severe symptomatic aortic and mitral stenosis. We described the acute hemodynamic results, immediate clinical outcomes, and complications in 27 patients treated consecutively at Hermann Hospital with either percutaneous balloon aortic or mitral valvuloplasty. We review the possible mechanisms of action of balloon valvulotomy and the current indications for either procedure. Balloon aortic valvuloplasty is indicated in elderly patients with severe aortic stenosis in whom open-heart surgery is contraindicated or carries excessive mortality. All patients with symptomatic mitral stenosis are potential candidates for balloon mitral valvulotomy. In centers with an experienced interventional team in transseptal catheterization and an active surgical program, balloon valvulotomy is the initial procedure of choice for significant mitral stenosis with mobile leaflets and minimal chordal thickening.
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Estenosis de la Válvula Aórtica/terapia , Cateterismo , Estenosis de la Válvula Mitral/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , HumanosRESUMEN
Potassium loss from damaged myocardial cells is linearly related to CPK enzyme loss reflecting extent of necrosis. The potassium analog, rubidium-82 (82Rb), is extracted after i.v. injection and retained in viable myocardium but is not trapped or washed out of necrotic regions. To compare myocardial cell metabolism with membrane dysfunction as indicators of necrosis/viability, 43 patients with evolving myocardial infarction and coronary arteriography had positron emission tomography using fluorodeoxyglucose (FDG) and the potassium analog 82Rb. Percent of heart showing FDG defects and 82Rb washout on sequential images indicating failure to retain the potassium analogue were visually assessed and quantified by automated software. Infarct size based on rubidium kinetics correlated closely with size and location on FDG images (visual r = 0.93, automated r = 0.82), suggesting that loss of cell membrane integrity for trapping the potassium analog 82Rb parallels loss of intracellular glucose metabolism, both comparable quantitative markers of myocardial necrosis/viability.