Cardiac motion in total electrical alternans.

Gross pendular motion of the heart at half the heart rate was observed during cardiac catheterization and pericardiotomy in a patient with massive pericardial effusion and electrical alternans in the electrocardiogram. These observations support the hypothesis that total electrical alternans in pericardial effusion is a result of alternate change in cardiac position.

Situs inversus, subaortic and subpulmonic stenosis, ventricular septal defect, and single coronary artery.

The unusual occurrence of situs inversus totalis, ventricular septal defect, hypertrophic subaortic and subpulmonic stenosis, and single coronary artery in a 38-year-old man is presented. The clinical course was remarkably mild, as documented by data from 23 years of study including four cardiac catheterizations. At age 35 years, however, syncope, chest pain, and marked elevation of right ventricular pressure prompted complete surgical repair of the left and right ventricular outflow tract obstructions and closure of the septal defect. Three years after surgery the patient continues to lead an active life without symptoms. The unusually mild course can be attributed to the natural banding effects of the subpulmonic stenosis which prevented irreversible pulmonary hypertension.

Delirium as the predominant manifestation of hyperparathyroidism: reversal after parathyroidectomy.

A 67-year-old woman who had primary hyperparathyroidism presented with delirium rather than dementia as the predominant psychologic manifestation. After surgical removal of a parathyroid adenoma, there was a dramatic improvement in mental status. Psychologic retesting at six weeks after discharge showed her to be well oriented to time, place, and person, with no impairment of cognitive capacity.

Giant peptic ulcers in patients with chronic renal failure.

The clinical characteristics and outcome of patients with peptic ulcer disease (PUD) in association with chronic renal insufficiency were compared with those of patients who had PUD without renal impairment. The number of patients hospitalized with PUD was 150, which represented 1.3% of all hospital admissions to Kingsbrook Jewish Medical Center over the two-year period August 1986 to August 1988. The incidence of PUD among the patients with end-stage renal disease was 2.6%. Mortality was significantly higher in patients with serum creatinine greater than 264 mumol/L (Group A) than in patients with serum creatinine less than 264 mumol/L (Group B) (p = 0.02). A striking finding was the presence of giant (greater than 2 cm in width) gastric and duodenal ulcers and ulcers of the second portion of the duodenum in both groups. The difference in number of giant ulcers in Group A and Group B was statistically significant (p less than 0.001). Moreover, the patients in Group A had a higher incidence of upper gastrointestinal bleeding and mortality than those in Group B. Group A patients also had a greater need for surgery than Group B patients. Both groups were predominantly elderly with a mean age greater than 65 years, which may have contributed to the increased incidence of complications and mortality.

Physical therapy and dance in the surgical management of breast cancer. A clinical report.

This report describes a creative therapeutic exercise program that is part of a preoperative and postoperative regimen prescribed for patients with breast cancer surgery. Since August 1982, physical therapy has been offered as part of a multidisciplinary breast cancer program at our acute-care hospital. Our physical therapy department provides preoperative and postoperative evaluations and treatment for patients with breast cancer surgery. This treatment is offered on an outpatient basis and includes group dance sessions that are supervised by a licensed physical therapist and a licensed dance teacher. Physical therapy for patients with breast cancer surgery need not be limited to traditional wall-climbing exercises. Early physical therapy intervention should be directed at the unique emotional and physical problems encountered by these patients. Through dance, patients may experience the freedom of total body movement that enhances their adjustment to a new body image. An organized group setting provides a support mechanism that enables patients to share their experiences, fosters a positive attitude toward exercise, and facilitates psychological adjustment to the diagnosis of breast cancer.

Bilateral renal artery occlusion in a patient with progressive systemic sclerosis.

A patient with renal failure due to progressive systemic sclerosis showed bilateral renal artery occlusion on renal angiography. The mechanism for the involvement of the main renal arteries is unknown, but it is postulated that the involvement of the main stem renal arteries was an extension of the pre-existing occlusive process in the interlobular arteries. This was hastened by the severe reduction in renal blood flow due to the hemorrhage and sepsis complicating the course. Another possible mechanism is a reduction of the fibrinolytic activity in the region of the intimal narrowing of the renal artery, coupled with reduction of the blood flow. The kidney biopsy showed intimal thickening and almost complete occlusion of interlobar arteries. Similar changes were observed in the smaller arteries. These findings are consistent with scleroderma of the kidney.

Transient hypoglycemic paraparetic syndrome in an elderly patient.

An elderly diabetic patient sustained a transient hypoglycemic paraparetic episode that was attributed to inappropriate administration of glyburide. There were no other predisposing causes to account for the transient hypoglycemia. The predominant clinical signs were paraparesis of the lower extremities, with the right side more affected than the left. The patient's paraparesis cleared within two hours after administration of 50 mL of 50 percent glucose intravenously.The management of a paraparetic syndrome should include an appraisal of all the predisposing factors and their correction. The mechanism that was deemed responsible for the patient's transient hypoglycemic paraparetic syndome was loss of cerebrovascular autoregulation in a vulnerable area (the vertebral-basilar artery distribution). In the elderly patient tight control of blood glucose levels should be avoided in view of the potential development of hypoglycemia and brain injury.

Hypernatremia in the aging: causes, manifestations, and outcome.

The incidence, clinical manifestations, morbidity, and mortality of all adult hypernatremic patients hospitalized during a 6-month period were studied. The impact of age on this parameter was evaluated, and the velocity of correction that produced best clinical results was established. Records of all patients who were admitted or developed hypernatremia (Na+ > 150 mEq/L) were reviewed. Demographic characteristics of age, gender, associated diagnosis, length of stay, source of admission, treatment, and outcome were recorded. Of 3209 hospitalizations, 111 patients were hypernatremic (3.46%). Sixty-five were admitted with hypernatremia, and 45 developed hypernatremia while hospitalized. Fifteen had recurrent episodes of hypernatremia. Forty-nine had associated hypokalemia and six had hypercalcemia. The etiology was multifactorial and varied with age. Correction of the hypernatremia within 4 days produced significant improvement in mental status. The overall mortality was 48.6%, and age did not favorably influence mortality. Hypernatremia is a common disorder of elderly hospitalized patients, associated with high mortality and morbidity. Other electrolyte disorders that impair the kidney concentrating ability frequently are observed. The etiology is multiple, and febrile illness due to bacterial infections is the most common cause among the elderly. Prompt treatment of infections and increased water intake in this group of patients could prevent its development. Correction over a 72-hour period significantly improved recovery of mental functions.

Hypokalemia: are elderly females more vulnerable?

This study was undertaken to evaluate the relationship between prevalence of hypokalemia and the age and sex of patients. Serum potassium concentrations of 872 patients were measured, and the prevalence of hypokalemia was compared between age and sex groups. Hypokalemia was more common in patients 65 years or older than in younger groups (P < .001), with a significantly higher frequency in female patients (P < .003). The finding was more common in elderly female patients than in elderly males (P < .002). No statistically significant difference was noted in the frequency of hypokalemia in elderly male patients compared with younger patients of either sex. The predominance of hypokalemia in elderly groups was chiefly attributable to a marked preponderance in elderly female patients over all other groups. Neither younger females nor elderly males were at increased risk. The preponderance in elderly females was not dependent on diuretic usage. It may have been due to age- and sex-associated differences in body mass composition, which result in a physiologically low total exchangeable body potassium in elderly females, placing this group at greater risk for developing hypokalemia.

The causes and frequency of acute hospitalization of patients with dementia in a long-term care facility.

A retrospective study of 81 patients with dementia in a long-term care facility was conducted to determine the causes and frequency of acute hospitalization and the cause of death in the patients who succumbed during the acute hospital admission. Pneumonia and urinary tract infections were the most frequent causes of acute hospitalization; septicemia and respiratory failure were the most frequent causes of death. These results suggest that patients with dementia are prone to acquire life-threatening infections. Preventive measures to decrease the incidence of these complications are discussed.