Usefulness of ischemic response to mental stress in predicting silent myocardial ischemia during ambulatory monitoring.

To evaluate the relation of mental stress-induced ischemia to silent ischemia on ambulatory monitoring, 46 patients with stable coronary artery disease underwent standardized laboratory mental stress and exercise treadmill testing according to National Institutes of Health protocol during which left ventricular ejection fraction (EF) was determined using the nuclear VEST. Life stress, type A behavior, and hostility were determined using standard interviews. Subsequently, 48-hour ambulatory electrocardiographic monitoring was performed. Twenty-three patients (50%) had an ischemic response (left ventricular EF decrease > or = 5%) to mental stress, which was associated with ambulatory ischemia (13 of 19 with ambulatory ischemia had mental stress-induced ischemia vs 10 of 27 without ambulatory ischemia, p = 0.04). Left ventricular EF response to mental stress was a significant predictor of ambulatory ischemia independent of EF response to exercise (F = 4.8, p = 0.03). Patients with mental stress-induced ischemia had longer total duration (31.4 +/- 57.0 vs 8.3 +/- 18 minutes, p = 0.06) and more frequent episodes of ambulatory ischemia (3.1 +/- 4.6 vs 0.9 +/- 1.9 episodes, p = 0.03). Life stress, type A behavior, and hostility were not associated with prevalence or severity of ambulatory ischemia. In conclusion, an ischemic response to mental stress is significantly associated with higher prevalence, longer duration, and more frequent episodes of ambulatory ischemia.

[Selective galactophorectomy for mono-orificial nipple discharge without associated mass: technique and results. Apropos of seventy-three cases]. / La galactophorectomie sélective pour l'écoulement mammaire uniorificiel sans masse associée: technique et résultats. A propos de soixante-treize cas.

A single duct mammary discharge is a sign of an underlying disease: inflammatory, benign proliferative disease or even cancer. Selective resection of a ductolobular tree insures appropriate diagnosis and causative and definitive treatment of the discharge. Mammogram is essential. Galactography is quite usefull and reliable but may be unindicated or contraindicated. Surgery includes catheterization of the hole, methylene blue dye staining of the duct, circumareolar or radial incision, dissection, pyramidal resection of the whole galactophoric tree and closure with a retracting suture of the nipple. Woman's age, color of the discharge, pre-operative galactography suggest the diagnosis which has been in our series of 73 cases an inflammatory process in 53.4% of cases, a benign proliferative in 42.5% of cases and an epithelioma in situ in 4.1% of cases. The 46 cases of serous, serosanguinous or sanguinous discharge were due to an inflammatory process in 15 cases (32.6%), a benign proliferative in 28 cases (60.9%) and an in situ carcinoma in 3 cases (6.5%).

Primary cardiac Burkitt-like lymphoma of the right atrium.

A 74-year-old man presented for shortness of breath. Echocardiography revealed the presence of a large pericardial effusion with signs of tamponade. A right atrial mass was suspected and later confirmed by transesophageal echocardiography. The mass was attached to the right side of the interatrial septum. Surgical resection was performed. Histology was compatible with a diagnosis of undifferentiated B-cell non-Hodgkin's (Burkittlike) primary cardiac lymphoma. The present report provides the first description of a Burkitt-like primary cardiac lymphoma. The presence of a mass in the right atria should raise the possibility of a malignant cardiac tumour. Transesophageal echocardiography should be considered as the initial diagnostic procedure to be performed. Rapid histological diagnosis is important because systemic therapy can influence prognosis in the presence of a primary cardiac lymphoma.

Vaginoplasty outcome in male-to-female transsexuals.

This study investigated the cosmetic and functional adequacy of the neovagina in surgically reassigned male-to-female transsexuals. Subjects were 22 transsexuals with a mean postsurgical follow-up of 4.4 years. All were given structured interviews followed by pelvic examinations. The majority of subjects reported at least some postoperative sexual responsiveness. Vaginal depth, measured with a specially constructed probe, averaged 8.3 cm. Only a minority of subjects, however, complained that the neovagina was inadequate for coitus. It is possible that transsexuals accomplish coitus, despite short vaginas, by assuming positions that limit the depth of their partners' thrusting.

Psychiatric morbidity during the early phase of coronary care for myocardial infarction: association with cardiac diagnosis and outcome.

We evaluated the association of psychiatric morbidity during the early phase of admission to a coronary care unit with cardiac diagnosis and subsequent morbidity. Ninety-two patients admitted for the first time for presumed myocardial infarction were evaluated within 48 hours of hospitalization. Anxiety and depressive symptoms and cognitive impairment were rated. Data were collected on cardiac diagnosis and morbidity. Three and 12 months after hospitalization, cardiac morbidity, psychiatric symptoms and psychosocial morbidity were assessed.

The remitting atypical psychoses: clinical and nosologic considerations.

There exists in the literature a group of nonorganic psychoses which appear to have no obvious relationship to either schizophrenia or affective illness. Diagnostic terminology to classify these atypical psychoses has been varied, although features in common can be identified. For example, they often are associated with antecedent personality problems, acute onset, florid and mixed symptomatology, brief duration, and full remission with a return to premorbid level of functioning. Case material reflecting these types of psychoses is presented here, and is discussed with reference to the nosologic status of these atypical psychoses.

The nosologic status of the remitting atypical psychoses.

For many decades clinicians have recognized the importance of some nonorganic psychoses that have no obvious relationship to either schizophrenia or affective illness. These atypical psychoses are characterized by sudden onset, florid and fluid symptoms, brief duration, remitting outcome, and a pattern of recurrences. They are presumed to be caused by major stress or characterologic defects or both. Systematic investigations into these conditions have been comparatively sparse. This report reviews the literature concerning these remitting atypical psychoses, proposes descriptive criteria for their recognition, and makes suggestions for further research.

Cumulation characteristics of cisatracurium and rocuronium during continuous infusion.

PURPOSE: The dissimilar pharmacokinetic properties of cisatracurium (CIS) and rocuronium (ROC) predict different potential for drug cumulation when these drugs are administered by continuous infusion. A study was therefore undertaken to compare cumulation potential of CIS and ROC during surgical procedures of relatively long duration (2-4 hr). METHODS: Sufentanil/propofol-N2O anesthesia was administered to 40 ASA I and II adults. In a double-blind protocol, patients were randomly allocated to receive a continuous i.v. infusion of either CIS or ROC, titrated in progressive increments or decrements as required to achieve and maintain 95 +/- 5% depression of the T1 response of the adductor pollicis muscle, using a Datex NMT-100 Relaxograph EMG monitor applied at the wrist. At the end of surgery, 60 microg x kg(-1) neostigmine plus 15 microg x kg(-1) atropine were administered for reversal. RESULTS: The duration of infusion was 104 +/- 33 min in group CIS and 110 +/- 23 min in group ROC (P=NS). In both groups, a progressive decrease in potency-adjusted infusion rates was observed after 30 min, then stabilized beyond 60 min. When allowing for an initial period of stabilization, mean potency-adjusted infusion requirements were: CIS 0.81 +/- 0.02 microg x kg(-1) x min(-1) and ROC 5.58 +/- 1.94 microg x kg(-1) x min(-1). There were no differences between groups at any time with regard to potency-adjusted infusion requirements necessary to maintain 90-99% block (P=NS). However, drug costs/hr for maintenance of neuromuscular block were less with CIS ($3.57 +/- 0.09) than with ROC ($6.03 +/- 0.27), P < 0.001. CONCLUSION: When adjusted to equipotency, infusion requirements of CIS and ROC vary at similar rates during general anesthesia. Despite pharmacokinetic differences, neither drug demonstrates cumulation for infusion lasting up to 3.5 hr.

Pathophysiology and time course of silent myocardial ischaemia during mental stress: clinical, anatomical, and physiological correlates.

OBJECTIVE: To define the prevalence and pathophysiology of myocardial ischaemia induced by mental stress in patients with coronary artery disease and exercise inducible ischaemia, and to determine the correlation between the severity of coronary artery disease and ischaemia induced by speech. DESIGN: Prospective cohort study. SETTING: Tertiary care academic institution. PATIENTS AND PROTOCOL: 47 patients with coronary artery disease and 20 normal controls were studied using standardised exercise and mental stress. The ambulatory nuclear vest provided continuous measures of left ventricular ejection fraction and relative volume changes: an ischaemic response to mental stress was defined as a decrease in ejection fraction of > or = 5% for > or = 60 s. Severity of coronary artery disease was assessed by the extent of thallium reversibility on exercise testing and the severity of angiographic disease. RESULTS: 23 (49%) of 47 patients with coronary artery disease had an ischaemic response to mental stress which occurred early, was sustained throughout the task and associated with an increase in end systolic volume. In contrast, the pattern of left ventricular response in the remaining 24 patients (51%) resembled that in the normal controls. Patients with mental stress induced ischaemia tended to have greater severity of coronary disease (mean (SD) total number of diseased vessels 1.9 (0.8) v 1.4 (0.9), P = 0.07), more frequent exercise induced angina (17/23 v 7/24, P = 0.003) and lower increases in heart rate (36 (11) v 49 (23) beats per min, P = 0.023) and systolic blood pressure (32 (19) v 45 (18) mm Hg, P = 0.03) during exercise. Left ventricular responses to speech and exercise were compared in the 23 patients with mental stress induced ischaemia: mental stress was associated with a greater decrease in ejection fraction at comparable increases in rate pressure product (-6.5 (6.3)% v 4.7 (11.2)%, P = 0.0001). CONCLUSIONS: These findings suggest that mental stress induction of myocardial ischaemia is common in patients with stable coronary artery disease. Susceptible patients may have more functionally severe coronary disease. The time course, pattern, and haemodynamic features of mental stress induced ischaemia suggest a dynamic decrease in coronary supply.

Intracellular regulation of estradiol and progesterone production by cultured bovine granulosa cells.

The objective of the present study was to investigate the implication of protein kinase A (PKA), protein kinase C (PKC), and receptor protein tyrosine kinase (R-PTK) pathways in the regulation of estradiol (E2) and progesterone (P4) production by bovine granulosa cells. Cells were harvested from bovine follicles (8-15 mm diameter) and cultured without serum for an initial 3 days (37 degrees C; 5% CO(2) in air; D1-D3). On the fourth day of culture (D4), E2 and P4 production were stimulated with FSH (1-6 ng/ml) or forskolin (FSK) in the presence or absence of intracellular effectors of PKA, PKC, and R-PTK. Culture medium was collected and replaced each day. Stimulation of granulosa cell adenylate cyclase activity with FSK (0.06-3.75 microM) mimicked FSH, inducing a quadratic increase (P < 0.001) of E2 production and a continuous elevation of P4 (P < 0.01). Inhibition of R-PTK activity with genistein (25-50 microM) increased the sensitivity of cells to FSH as demonstrated by a leftward shift in the dose response curve (P < 0.001). Treatment with transforming growth factor-alpha (TGFalpha; 0. 1 ng/ml) abolished the FSH-induced E2 production (P < 0.001) and this effect was not reversed (P < 0.001) by FSK or by genistein. Furthermore, the inhibitory effect of TGFalpha on FSH-induced E2 production was reproduced by phorbol 12-myristate 13-acetate (PMA; 1. 25-2.5 microM), a PKC activator (P < 0.001). Interestingly, genistein inhibited P4 production (P < 0.05). From these results, we conclude that E2 production by bovine granulosa cells is mediated by intracellular factors and can be stimulated downstream from the FSH receptor. The results also suggest that stimulation of R-PTK and/or PKC activities, as probably occurs with TGFalpha, negatively affects the PKA pathway, thus decreasing E2 production. Furthermore, inhibition of R-PTK leads to an increase production of E2 and may limit luteinization of bovine granulosa cells.

Depression and body image following mastectomy and lumpectomy.

A twenty year debate about the appropriate surgery for breast cancer has resulted in two clinical trials comparing radical vs more conservative operations. Despite the favorable results of these trials, the majority of breast cancer patients in North America still undergo mastectomy. We investigated the psychological and social adjustment following total and partial mastectomy in a group of patients randomly assigned to one or the other operation (National Surgical Adjuvant Breast Protocol--B-06). Total mastectomy patients showed higher levels of depression and less satisfaction with body image. Partial mastectomy patients did not display any measurable increase in fear of recurrence. Patients undergoing radiation therapy showed surprising increase in depressive symptoms. Radiation therapy could well be more frightening to breast surgery patients than had been anticipated. These patients may benefit from some anticipatory counselling.

Individualized aminoglycoside dosage regimens in patients with cystic fibrosis.

Individualized dosage regimens have recently been recommended for patients treated with aminoglycoside antibiotics. We have developed a calculator-based program for our patients with cystic fibrosis and have studied 93 courses of intravenous aminoglycoside treatment, comparing predicted and measured values in 45 courses. Pharmacokinetic parameters differed notably among subjects: this was reflected by widely variable total daily aminoglycoside dosage requirements. The mean daily dosage requirements (+/- SD) for tobramycin (62 treatment courses) was 13.0 +/- 3.74 mg/kg, and for gentamicin (26 treatment courses) was 11.5 +/- 2.6 mg/kg. The accuracy of the program was evaluated by its ability to predict peak and trough values in individuals: 84 percent of measured peaks were within 2 micrograms/ml of the predicted level. Nephrotoxicity was observed in one patient, ototoxicity in three. This program provides a simple, safe, and effective method of tailoring an aminoglycoside regimen to the patient's needs.