Multiple spontaneous small bowel perforations due to clozapine-Case report.

INTRODUCTION: Spontaneous free perforation of the small bowel is unusual. There are many causes of spontaneous small bowel free perforation such as: immune-mediated or inflammatory, infections, drugs and biological agents, congenital, metabolic, vascular and neoplasm. A severe adverse effect of antipsychotic drugs is intestinal ischemia, which could lead to perforation. CASE PRESENTATION: The authors report the clinical case of a 42-year-old schizophrenic patient, smoker, medicated with clozapine 600 mg per day, admitted to the emergency room with diffuse abdominal pain. On physical examination the patient presented abdominal rebound tenderness and peritoneal sign with raised inflammation markers and the abdominal tomography revealed pneumoperitoneum. An emergency laparotomy revealed multiple jejunal and ileal perforations. The patient was subject to small bowel resection complicated with anastomosis dehiscence, respiratory tract infection and intra-abdominal abscess. Histologic specimens showed nonspecific inflammatory findings with ischemia. The main infectious, inflammatory, congenital, auto-immune and vascular causes of spontaneous perforations were excluded. DISCUSSION: Spontaneous free perforation of the small bowel is uncommon. An intestinal ischemia might be a rare adverse effect of antipsychotics. However, only colon perforations due to ischemic colitis are described in the literature. While diagnosis of the precise cause might be challenging, and after excluding other causes, these perforations may be attributed to an adverse effect of clozapine. CONCLUSION: The cause was attributed to clozapine as the other etiologies were excluded. The clozapine's reintroduction is controversial. In this case the clozapine dose was reduced successfully.

Air pollution at an urban traffic tunnel in Lisbon, Portugal: an INAA study.

In this study, the results of chemical concentrations inside and outside of a Lisbon (Portugal) traffic tunnel were compared, during one week. They were obtained by Instrumental Neutron Activation Analysis (INAA). The tunnel values largely exceed the Air Ambient legislated values and the Pearson Correlations Coefficients point out to soil re-suspension/dispersed road dust (As, Ce, Eu, Hf, Fe, Mo, Sc, Zn), traffic-markers (Ba, Cr), tire wear (Cr, Zn), break wear (Fe, Zn, Ba, Cu, Sb), exhaust and motor oil (Zn) and sea-spray (Br, Na). On all days these elements inside the tunnel were more enriched than outside; significant statistical differences were found for Co (p=0.005), Br (p=0.008), Zn (p=0.01) and Sb (p=0.005), while enrichment factors of As and Sc are statistically identical. The highest values were found for As, Br, Zn and Sb, for both inside and outside the tunnel.

[Non-infectious thrombotic endocarditis: a case report]. / Endocardite trombótica não infecciosa: a propósito de um caso clínico.

A 48 year-old female patient, admitted with an ischemic stroke, had a transesophageal echocardiogram (TEE) that revealed a dense vegetation in the noncoronary aortic cusp, which was considered the probable source of embolism. The clinical investigation did not identify any other disease or infectious process. However the lack of histologic proof, the absence of fever, the fact that the blood cultures were persistently negative, the patient recovery with no need of antibiotics, and the results of the TEE, are highly suggestive of the presence of a non infectious thrombotic endocarditis. After 18 months of anti-platelet treatment, the patient showed no new embolic episodes and TEE demonstrated the resolution of the vegetation.

Role of myocardial ischemia and left ventricular wall motion abnormalities as contributory factors in the genesis of exercise-induced ST-segment elevation in Q-wave myocardial infarction.

In patients with a previous myocardial infarction, controversy exists regarding the significance of postexercise ST-segment elevation in the infarct-related leads. Although usually admitted to be a sign of left ventricular dysfunction or myocardial aneurysm, other studies however have related this finding to transient myocardial ischemia and to the presence of jeopardized but viable myocardium in the infarct area. The aim of the present study was to assess the significance of postexercise ST-segment elevation in Q-wave leads as a marker of transmural ischemia or left ventricular dysfunction in 36 consecutive patients, 16 with exercise-induced ST-segment elevation in infarct-related leads. Patients were evaluated by treadmill exercise testing, coronary angiography and ventriculography, thallium-201 tomographic scintigraphy and radionuclide ventriculography within 3 months of the first myocardial infarction. Sixteen patients (group I) had exercise-induced ST segment elevation and 20 (group II) postexercise inversion, no change or pseudonormalization of the T wave in infarct-related leads. The study showed no difference in infarct-related artery, vessel disease or luminal diameter stenosis in groups I and II. The overall agreement between ST shifts and myocardial perfusion in the infarct area was 30.56% with a kappa coefficient of -0.33 (p = NS). The overall agreement between ST shifts and wall motion abnormalities was 69.44% with a kappa coefficient of 0.39 (p < 0.01), stress-induced ST-segment elevation being associated with severe wall contractile disorders in 85% of the patients. In conclusion stress-induced ST-segment elevation in Q wave leads, although not a marker of wall motion abnormalities, is associated with akinesia or dyskinesia of the left ventricular wall.

[The Internet as a solution facilitating the identification of patients with a suspected acute myocardial infarct]. / A Internet como solução facilitadora da identificação de doentes com suspeita de enfarte agudo do miocárdio.

The current steps for diagnosing heart disease are very time consuming, delaying the correct identification of the problem, therefore, delaying the right treatment. In this study we have developed an experimental method using e-mail in order to identify patients with "rule out myocardial" condition and reduce the time lag for thrombolysis or coronary angioplasty in this clinical setting. Three different locations linked to the Internet by ISDN lines were used. Each line was connected with a computer. A pager and a dedicated phone line were also used. The following steps were performed for each situation: filling out of a questionnaire, ECG recording, questionnaire mailing and ECG by e-mail as attachment, pager warning that an urgent cardiology consultation was requested, including the doctor and patient's phone number, time to open the message and reply by e-mail, phone call for additional comments. A total of 24 attempts of interactive communication were performed. In 22 of those, an answer was obtained in less than 30 minutes. Two failures were recorded. One was due to a delay in the pager message, which did not arrive within the first hour; the second was due to a computer break down. This report shows that it is possible to establish a fast communication between the out patient clinic and the hospital (less than 30 minutes in most cases) at a very low cost and in a simple manner.

Comparison between dobutamine echocardiography and thallium-201 scintigraphy in detecting residual stenosis, ischemia, and necrosis in patients with prior myocardial infarction.

BACKGROUND: Following the first attempts to detect myocardial ischemia with two-dimensional echocardiography stress testing, pharmacologic stress using dobutamine infusion has become an alternative to echocardiography exercise testing for evaluation of coronary artery disease. It has been shown that stress echocardiography has a diagnostic accuracy similar to that of an exercise thallium test. Other studies, however, indicated that radionuclide myocardial perfusion imaging was more sensitive than exercise or pharmacologic stress echocardiography for detection of ischemia or jeopardized myocardium. HYPOTHESIS: The aim of the present study was to determine the ability of dobutamine stress echocardiography in comparison with thallium-201 scintigraphy to identify multivessel disease and the presence of myocardial scar and ischemia in 60 consecutive patients who suffered a first myocardial infarction (MI). METHODS: Patients were evaluated by coronary angiography and ventriculography, thallium-201 (201TI) tomographic scintigraphy, and dobutamine echocardiography within 3 months of a first MI. Forty-seven had Q-wave MI and 13 had non-Q-wave MI. Eleven patients were excluded from final analysis-7 because of failure to achieve target heart rate in spite of the use of atropine, and 4 because of high blood pressure following the infusion of dobutamine. RESULTS: Dobutamine echocardiography showed an overall sensitivity of 43% for detection of coronary artery lesions of 50-74% diameter stenosis and 201TI scintigraphy showed a sensitivity of 71%. For detection of lesions of > or = 75% diameter stenosis, dobutamine echocardiography showed a sensitivity of 52% and 201TI a sensitivity of 70%. Overall agreement between wall motion and myocardial perfusion for detection of necrosis and/or ischemia in the infarct area was 40.4% with a kappa coefficient of 0.09 (p = 0.13). For detection of ischemic myocardium outside the infarct zone, overall agreement was 78.6% with a kappa coefficient of 0.49 (p < 0.0001). CONCLUSION: Dobutamine echocardiography results showed a lower sensitivity than myocardial perfusion images in predicting multivessel coronary artery disease, and there was poor agreement between both methods in identifying necrosis or ischemia.

[Coronary artery disease, myocardial perfusion and ventricular function in Q-wave and non-Q-wave myocardial infarcts]. / Doença arterial coronária, perfusão miocárdica e função ventricular em enfartes do miocárdio com onda Q e sem onda Q.

Controversy remains in considering non-Q wave myocardial infarction (NQMI) a distinct pathophysiological entity of Q wave myocardial infarction (QMI). In order to analyze the severity of coronary artery disease, extension of myocardial scar or myocardial ischemia and ventricular function, 78 consecutive patients with QMI and 32 with NQMI, mean age 55.4 +/- 8.5, not submitted to thrombolytic therapy, were studied. Coronary angiography, exercise thallium scintigraphy and radionuclide ventriculography were performed in all at least within 3 months of a prior myocardial infarction. In the present study the occurrence of QMI was significantly more frequent in older patients than NQMI. There was no prevalence of occlusion either in the right, left circumflex or left anterior descending coronary arteries in both groups. Ejection fraction, degree of occlusion and presence of collateral circulation showed an equal prevalence in QMI and NQMI patients. A higher incidence of multivessel disease was found in NQMI that had less necrosis than QMI patients. The prevalence of exercise induced thallium-201 redistribution defects within the infarct zone was substantially higher and involved more scar segments in NQMI patients. Physiological and clinical consequences of coronary thrombosis depends on the size and the number of diseased arteries, the approach the pathophysiologic consequences of coronary disease in terms of fractal structure has been suggested. A pronounced heterogeneity in regional myocardial blood flow in a fractal branching arterial network may be responsible for the pathophysiologic differences of coronary thrombosis between Q-wave and non Q-wave infarction.

[Thrombolytic therapy in acute myocardial infarct--is it being used to the fullest?]. / Terapêutica trombolítica no enfarte agudo do miocárdio--estará a ser utilizada em pleno?

OBJECTIVE: To evaluate the experience with thrombolytic therapy (TT) in the treatment of patients with the discharge diagnosis of acute myocardial infarction (AMI). DESIGN: Retrospective analysis of the clinical records of patients with the discharge diagnosis of AMI, between May 1988 and December 1995. SETTING: Intensive Cardiac Care Unit (UCIM-Medicina IV) of Santa Maria University Hospital, Lisbon, Portugal. PATIENTS: 1319 patients, 958 men (73%) and 361 women, mean age 64 +/- 12 years. MAIN RESULTS: Thrombolytic therapy was administered in 391 patients (30%). Female patients received less thrombolytic therapy compared with male (17% vs. 34%; p < 0.001). Anterior wall infarction was more frequent (38%). Patients in Killip class I-II (77%) received more thrombolytic therapy than class III-IV (33% vs. 17%). The utilization rate of thrombolytic therapy increased from 25% in 1988 to 34% in 1995. Two major categories of patients were not treated with thrombolysis: 1) patients presented more than 12 hours after pain onset (38%); 2) patients without ST segment elevation or LBBB on the ECG presented (37%). Overall hospital mortality was 15.6%. The mortality in patients receiving thrombolytic therapy was significantly lower than in those excluded (9.4% vs. 18.2%; p < 0.001). CONCLUSION: Only 30% of patients with AMI receive TT. Of those excluded from this important therapeutic intervention, 75% had no ECG criteria or were outside the standard therapeutic "window". This significant group of patients need new diagnostic and intervention strategies.

[Dobutamine stress echocardiography in patients after an acute myocardial infarct: what is the significance of arterial patency related to the infarct?]. / Ecocardiografia de sobrecarga com dobutamina nos doentes pós-enfarte agudo do miocárdio: qual a importância da permeabilidade da artéria relacionada com o enfarte?

BACKGROUND: Dobutamine stress echocardiography is a very promising technique for assessing myocardial viability, ischemia and prognosis in patients with a recent acute myocardial infarction. Recent studies have shown that the type of perfusion in the infarct-related artery also plays a role in the prognosis of these patients. PURPOSE: To evaluated in patients with non complicated infarction the ability of low-dose and high-dose dobutamine stress echocardiography to assess the presence of both viability and inducible ischemia and correlate the results with the patency of the infarct related artery and the accuracy to predict cardiac events during one year follow-up. PATIENTS AND METHODS: Fifty one consecutive in-hospital patients (47 male and four female, mean age 52 +/- 11 years, range 31-75 years) with acute myocardial infarction were evaluated both by dobutamine stress echocardiography and by coronary angiography and followed-up for a mean of 12 +/- 8 months. RESULTS: With low-doses of dobutamine, the incidence of myocardial viability was 33% and with high-doses, the incidence of residual inducible ischemia was 41%. The patency of infarct-related artery showed significant correlation with score wall motion index for viability and for myocardial ischemia. Twenty four (47%) patients suffered cardiac events. Dobutamine stress echocardiography showed a positive predictive value of 67% and a negative of 70% and identified high and low risk patients. CONCLUSIONS: Dobutamine stress echocardiography in patients with acute myocardial infarction is a safe and well tolerated test, and provides in a single test useful information regarding viability, ischemia and prognosis.

[Stress echocardiography with dobutamine: the importance of adding atropine in inconclusive tests]. / Ecocardiografia de sobrecarga com dobutamina: a importância de adicionar atropina nas provas inconclusivas.

OBJECTIVES: To study the feasibility of adding atropine after dobutamine infusion in patients with known or suspected coronary artery disease not achieving 85% of predicted maximal heart rate. PATIENTS: We studied with dobutamine stress echocardiography 219 patients (174 men e 45 women; mean age +/- SD: 58 +/- 11 years), 126 patients with a previous myocardial infarction and 93 with angor. One hundred and thirty three (61%) also performed coronariography. METHODS: Dobutamine stress echocardiography protocol consisted of a step-wise infusion of dobutamine from 5 micrograms/kg/min to a maximal dose of 40 micrograms/kg/min or until a new or a worsening wall motion abnormality, 85% of predicted maximal heart rate or any indication for interruption. In patients not achieving any of these end points, intravenous atropine was administered up to 1 mg. Patients were divided in two groups: Group A: infusion of dobutamine alone and Group B: dobutamine plus atropine. RESULTS: With this protocol the test was interrupted in 41 patients (19%) because of adverse effects that were mild and short lived and resolved with discontinuation of the test. After dobutamine infusion 46% of the tests were nonconclusive, the majority were on beta blocker therapy. After atropine administration there was a significant reduction of the nonconclusive studies to 20% (p < 0.001). In patients with a normal rest echocardiogram the sensitivity and specificity of the test to diagnose significant coronary artery disease was respectively 89% e 100% after atropine. The capacity of the test to detect multivessel disease was also increased after atropine, allowing to reach a sensitivity of 85% and a specificity of 90%. CONCLUSIONS: Dobutamine stress echocardiogram supplemented with atropine is a safe and accurate method to diagnose significant coronary artery disease and to detect multivessel disease in patients with a previous myocardial infarction with rest wall motion abnormalities.

Minimal residual coronary obstructions in patients who suffered a first myocardial infarction. A prospective study comparing coronary angiography and exercise thallium scintigraphy.

The purpose of the present study was to correlate the presence of minimal coronary obstruction (< or = 50%) assessed by coronary angiography with the presence of myocardial scar and ischemia detected by thallium-201 myocardial perfusion imaging. The study included 83 consecutive patients (74 men and 9 women) with a mean age 55.4 +/- 8.5 years who suffered a first myocardial infarction and did not undergo thrombolytic therapy. In all patients, coronary angiography, left ventriculography, and exercise thallium-201 tomographic scintigraphy were performed within 3 to 5 months of the myocardial infarction. Coronary arteriograms showed minimal residual obstructions in 37 (45%) patients. Of a total of 54 patients with < or = 50% obstruction, 18 showed persistent defects and 22 reversible defects on thallium scintigrams. The present study showing estimated angiographic stenosis of < or = 50% as being responsible either for myocardial scar or myocardial ischemia on postexercise thallium scintigrams leads us to conclude that percent value of stenosis does not accurately predict the pathophysiologic significance of coronary atherosclerotic lesions in patients who suffer a myocardial infarction. After a first myocardial infarction, coronary angiographies and thallium-201 scintigrams are complementary for an optimal treatment strategy for selected subsets of patients.

Postexercise changes of the QTc interval in patients with recent myocardial infarction.

A lack of the QTc ratio decrease at maximal exercise is considered as an index of exercise-induced ischemia in patients with coronary artery disease. The authors studied 51 patients with recent myocardial infarction in order to evaluate the QTc changes with exercise in assessing the presence of remaining ischemic myocardium. All patients were submitted to exercise stress tests, coronary angiographies, and exercise thallium 201 scintigraphies within 3-5 months of the myocardial infarction. Of the patients studied, 18 showed one-vessel disease and 33 showed multivessel disease. All vessels were classified as patent or occluded. In all patients with reversible thallium 201 defects both at distance and in the infarct zone, the QTc interval following exercise either showed a prolongation or no change from the resting electrocardiogram. In patients with only fixed perfusion defects, the QTc shortened at the end of the test. This study showed a low sensitivity and specificity for inducible ST-segment depression compared with the delayed redistribution on the postexercise thallium 201 scintigram. QTc variations at the end of exercise electrocardiograms are valuable as a noninvasive, low-cost identification of residual ischemic myocardium in patients after myocardial infarction.

[Significance exercise-induced ST elevation in patients with myocardial infarction]. / Significado do supradesnivelamento ST de esforço em doentes com enfarte do miocárdio.

In 52 patients with previous myocardial infraction, 49 men and 3 women (mean age 56 +/- 7.1 years) the significance of ST-segment elevation during the stress-test, was evaluated. Of the 52 patients 15 (29%) showed St-segment elevation and 37(71%), showed no alteration of the ST-segment. Extension of coronary disease, degree of obstruction, wall motion abnormalities and the presence of residual ischemia were evaluated by coronary angiography, technetium-99M pyrophosphate imaging and exercise TL-201 scintigraphy. From the results of the study one may conclude that, in patients with previous myocardial infraction exercise, ST-segment elevation is a consequence of sub-occlusion of the left anterior descending coronary artery with severe ventricular dysfunction either in patients with one or multiple vessel disease.

[Equilibrium radionuclide angiography in patients with previous myocardial infarct. Correlation with electrocardiogram and coronarography]. / Angiografia de radionuclídos de equílibrio em doentes com enfarte do miocárdio prévio. Correlação com o electrocardiograma e a coronariografia.

Fifty five patients with previous myocardial infarction (MI), 47 male and 8 female, mean age 55.5 +/- 8.9 years, have been studied in order to correlate the alterations found on the equilibrium (gated) radionuclide angiogram (RNA) with the location of the MI on the electrocardiogram of the obstructive lesions on coronary angiographies. Of the 55 patients studied, 22% showed no regional wall motion abnormalities (WMA). Both MI with and without Q wave may show WMA, which are significatively more frequent in patients with anterior MI on the ECG and with occlusive lesions (greater than 90%) on coronariographies. Regional localization of the WMA on the RNA does not identify the localization of the obstructive lesions. Hypokinesia was the most frequent type of WMA found both with occlusive (greater than 90%) and sub-occlusive (greater than 75%) lesions. Low values of the ejection fraction (less than 45%) were found in the presence of WMA and occlusive artery lesions.