Impaired cardiovascular structure and function in adult survivors of severe acute malnutrition.

Malnutrition below 5 years remains a global health issue. Severe acute malnutrition (SAM) presents in childhood as oedematous (kwashiorkor) or nonoedematous (marasmic) forms, with unknown long-term cardiovascular consequences. We hypothesized that cardiovascular structure and function would be poorer in SAM survivors than unexposed controls. We studied 116 adult SAM survivors, 54 after marasmus, 62 kwashiorkor, and 45 age/sex/body mass index-matched community controls who had standardized anthropometry, blood pressure, echocardiography, and arterial tonometry performed. Left ventricular indices and outflow tract diameter, carotid parameters, and pulse wave velocity were measured, with systemic vascular resistance calculated. All were expressed as SD scores. Mean (SD) age was 28.8±7.8 years (55% men). Adjusting for age, sex, height, and weight, SAM survivors had mean (SE) reductions for left ventricular outflow tract diameter of 0.67 (0.16; P<0.001), stroke volume 0.44 (0.17; P=0.009), cardiac output 0.5 (0.16; P=0.001), and pulse wave velocity 0.32 (0.15; P=0.03) compared with controls but higher diastolic blood pressures (by 4.3; 1.2-7.3 mm Hg; P=0.007). Systemic vascular resistance was higher in marasmus and kwashiorkor survivors (30.2 [1.2] and 30.8 [1.1], respectively) than controls 25.3 (0.8), overall difference 5.5 (95% confidence interval, 2.8-8.4 mm Hg min/L; P<0.0001). No evidence of large vessel or cardiac remodeling was found, except closer relationships between these indices in former marasmic survivors. Other parameters did not differ between SAM survivor groups. We conclude that adult SAM survivors had smaller outflow tracts and cardiac output when compared with controls, yet markedly elevated peripheral resistance. Malnutrition survivors are thus likely to develop excess hypertension in later life, especially when exposed to obesity.

Intracoronary stent implantation in Jamaica: the initial experience

Intracoronary stent implantation resulted in the complete or near complete dilatation of high gread occlusions of the left anterior descending coronary arteries in the four patients in whom it was undertaken. Intracoronary stent implatation is a useful adjuct to Percutaneous Transluminal Angioplasty (PTCA) and is applicable in selected patients with symptomatic ischaemic heart disease in a developing country with limited health resources like Jamaica. This is so since financial data presented here document the significant savings this technique (when appropriately utilised) could realise compared to the use of baloon angioplasty alone. (AU)

Percutaneous balloon mitral valvuloplasty for severe rheumatic mitral stenosis in Jamaica: the initial experience

Although percutaneous balloon mitral valvuloplasty has been performed in the Caribbean before, there has not been any detailed description in the English-speaking West Indian Medical literature hitherto. This report provides a description of the first four case of percutaneous balloon mitral valvuloplasty performed in Jamaica(AU)

Percutaneous transluminal coronary angioplasty (PTCA) in Jamaica: preliminary results

This is the first detailed report from the Anglophone Caribbean of percutaneous transluminal coronary angioplasty (PTCA). The procedure resulted in complete dilatation of the occluded vessels in the five patients in whom it was undertaken, with significant improvement in exercise duration in the Bruce protocol (p<0.001; 95 percent CI 2.5 to 4.1 minutes) in the four patients who were studied. PTCA can be undertaken in developing countries with limited resources, and should be offered to selected patients with symptomatic coronary artery disease who need a revascularisation procedure.(AU)

Asymptomatic cardiac involvement in systemic lupus erythematosus

Cardiologic and laboratory parameters were studied in 21 patients with systemic lupus erythematosus (SLE) with cadiopulmonary symptoms (CPS), 20 SLE patients without CPS and 45 age-and sex- matched healthy controls. The most frequent cardiac abnormalities in patients with CPS included pericardial effusion (24 percent), ventricular enlargement (20 percent), mitral regurgitation (19 percent) and tricuspid regurgitation (14 percent). No structural abnormalities were observed in SLE patients without CPS. Mean calculated and derived echocardiacgraphic values in both groups of SLE patients differed significantly from those observed in normal controls (p< 0.004). Patients with CPS had significantly lower mean values of ejection fraction (p< 0.05) and fractional shortening (p< 0.03). However, the frequencies of functional abnormalities in patients with CPS did not differ significantly from those observed in patients without CPS. There were no remarkable laboratory findings in SLE patients with CPS compared to those without. The finding that some SLE patients may have functional cardiac abnormalities in the absence of CPS is an important one. It raises the question as to whether asymptomatic cardiac involvement in SLE is a separate entity or whether it heralds symptomatic cardiopulmonary involvement (AU)

Asymptomatic cardiac involvement in systemic lupus erythematosus

Cardiologic and laboratory parameters were studied in 21 patients with systemic lupus erythematosus (SLE) with cadiopulmonary symptoms (CPS), 20 SLE patients without CPS and 45 age-and sex- matched healthy controls. The most frequent cardiac abnormalities in patients with CPS included pericardial effusion (24 per cent), ventricular enlargement (20 per cent), mitral regurgitation (19 per cent) and tricuspid regurgitation (14 per cent). No structural abnormalities were observed in SLE patients without CPS. Mean calculated and derived echocardiacgraphic values in both groups of SLE patients differed significantly from those observed in normal controls (p< 0.004). Patients with CPS had significantly lower mean values of ejection fraction (p< 0.05) and fractional shortening (p< 0.03). However, the frequencies of functional abnormalities in patients with CPS did not differ significantly from those observed in patients without CPS. There were no remarkable laboratory findings in SLE patients with CPS compared to those without. The finding that some SLE patients may have functional cardiac abnormalities in the absence of CPS is an important one. It raises the question as to whether asymptomatic cardiac involvement in SLE is a separate entity or whether it heralds symptomatic cardiopulmonary involvement

The development of echocardiography at the UWI - abstract

Echocardiography was first performed at University Hospital of the West Indies in 1981. The M-mode technique was employed, utilizing a Smith-Kline-French echocardiograph with a strip chart recorder. Two-dimensional echocardiographic studies began to be offered in 1984, utilizing a General Electric (General Ultrasound) machine sited in the X-ray Department. The resolution of the images obtained, however, was limited. From 1988 to 1989, better resolution was attained by the use of an Ultramark 4 echocardiograph which the Medical Research Council Laboratories (Jamaica) allowed use of for University Hospital patients. Basic pulsed wave doppler capability could also be offered. In 1989, the UWI Department of Medicine obtained an Ultramark 6 echocardiograph which allowed full two-dimensional imaging, pulsed and continuous wave doppler and colour flow mapping. Between July 1989 and December 1992, 5,276 echocardiograms (50 percent males, 50 percent females) were performed, using this machine, and a wide variety of cardiovascular diagnoses were made. Future plans include the development of transoesophageal echocardiography at the UHWI which will greatly expand diagnostic capabities (AU)

Pulmonary artery pressure and the acute chest syndrome in homozygous sickle cell disease

OBJECTIVE; to investigate whether attacks of acute chest syndrome affected pulmonary artery pressure in patients homozygous for sickle cell disease. MAIN OUTCOME MEASURES: Pulmonary artery pressure, assessed by non-invasive echocardiographic techniques. PATIENTS; 20 patients with homozygous sickle cell disease with a history of at least six episodes of acute chest syndrome and in 20 age, sex, and height matched controls with homozygous sickle cell disease without a history of acute chest syndrome. RESULTS: There was no difference in any of the echocardiographic or Doppler indices between these two groups. CONCLUSIONS: Repeated attacks of acute chest syndrome by the mean age of 12 ( range eight to 16 ) years have not had a discernible effect upon pulmonary artery pressure (AU)

The heart and systemic lupus erythematosus - abstract

A prospective clinical, serological and echocardiographic study of consecutive patients with systemic lupus erythematosus (SLE) and cardiopulmonary symptoms (Group 1) and 10 asymptomatic SLE patients (Group 11) was carried out. Both groups were then subsequently compared to 45, age and sex matched controls taken from the general population. The most common cardiac manifestation of SLE was pericardial effusion (5 patients; 24 percent). Other echocardiographic findings were: enlarged left ventricle (3 patients; 14 percent), large right ventricle (2 patients; 10 percent) myocarditis (2 patients; 10 percent), Libman Sacks endocarditis (1 patient; 5 percent). Doppler studies showed a 19 percent incidence of mitral regurgitation (4 patients), 14 percent tricuspic regurgitation (3 patients), 10 percent pulmonary hypertension (2 patients). Echocardiographic measurements in Groups 1 and 11 showed no statistically significant difference in left ventricular diastolic (LVDD) and systolic (LSVD) dimensions, and in end diastolic (EDV) and end sytolic volumes (ESV). There was increased heart rate and decreased stroke volume and cardiac index in Group 1. Indeed, there was no echocardiographic abnormality in Group 11. When both groups were compared to Group 111, there was stastically significantly lower ejection fraction and fractional shortening, greater septal and posterior wall thickness and smaller right ventricular diastolic dimension (RVDD) in the combined SLE group. The left ventricular mass in the SLE group was not increased but there were decreased stroke output and systolic function compared to the normal controls. Only one patient was positive for antiphospholipid antibody and she was in group 1. All SLE patients were antinuclear antigen positive (ANA) and antidouble stranded DNA antibodies were the most frequently found ANA in both groups 1 and 11. There was no statiscally significant difference in the prevalence of any ANA specificity between groups or between those patients with valvular abnormality and those without. Echocardiography was a more sensitive indicator of pericarditis/pericardial effusion than chest roentgenogram or electrocardiogram (AU)

Closed mitral valve commissurotomy in West Indian patients results of operative palliation (1955 to 1985)

A retrospective study of all patients subjected to closed mitral valve commissurotomy from 1955 to 1985 at the University Hospital revealed low morbidity and mortality rates associated with surgery. Out-patient follow-up studies indicate adequate symptomatic relief over a period of 1 to 27 years. Patients with isolated significant mitral stenosis should, therefore, be considered for surgical palliation (AU)

Mitral stenosis in West Indian patients: results of closed mitral commissurotomy (1955-1985) at the University Hospital of the West Indies - abstract

Mitral stenosis (MS) is not infrequently seen in patients presenting at referral clinics in the University Hospital (UH). These patients are offered surgical palliation - Closed mitral commissurotomy (CMC) - as published reports indicate such therapy is quite satisfactory. A study of all patients subjected to CMC for MS at UH was undertaken to evaluate the results of this operation. There were 97 women and 23 men and their ages ranged from 9 to 57 years (mean 24.7). A clinical diagnosis of MS was made in all patients. Thirty-four and 28 patients were subjected to cardiac catheterisation and echocardiography respectively to confirm the clinical diagnosis and /or to exclude other cardio-vascular abnormalities. The operative procedures performed were as follows: CMC - 117, CMC + lung biopsy - 1, Thoracotomy - 1, Prosthetic aortic and mitral valve replacement (failed CMC) - 1, Total = 120; Subsequent operations performed were as follows:- CMC - 1, Homograft mitral valve replacement - 5, Porcine xenograft mitral valve replacement - 3, Tracheostomy - 1, Thoracotomy (tamponade2, no tamponade 2) - 4, Total = 14. There were 3 intra-operative deaths (left coronary embolus, bleeding, acute cardiac failure), a 2.5 per cent mortality. Five and 9 patients died in the early and late post-operative periods respectively (cardiac failure, systemic embolisation, re-stenosis, re-operative), 4.2 and 7.5 per cent mortality. Follow-up studies after CMC indicate adequate symptomatoic relief over a period of 1 to 27 years. The results of CMC at UH indicate that the techniques of anaesthesia and surgery are associated with low morbidity and mortality. Patients with MS should therefore be considered for surgical palliation (AU)

Left atrial myxoma: an unusual cause of acute pulmonary oedema

A case of left atrial myxoma presenting as acute pulmonary oedema is described. As far as we are aware, this is the report in the West Indian medical literature of accurate pre-operative diagnosis and successful surgical excision of such a tumour. Recent improvements in the accuracy of pre-operative diagnosis are discussed, and the present day availability of surgical excision, utilising cardio-pulmonary bypass with excellent post-operative results at low-risk, make response of this case of considerable importance. (AU)

Acute rupture of the knee joint in rheumatoid arthritis

Two cases of acute rupture of the knee joint are described. The use of arthrography in diagnosis is demonstrated, and the aetiology and management briefly discussed (AU)

Chronic subdural haematoma: a clinical survey

Seventy-four cases of proven chronic subdural haematoma seen at the University Hospital of the West Indies between 1962 and 1971, were reviewed. The main problem associated with this condition remains one of diagnosis. The increasing incidence with age, and the increasing age and incidence of trauma in the population add to the relevance of a study of this condition. The clinical features are diversed and, for the most part non-specific; thus, the basis for initiating the diagnosis is still an adequate history and a high index of suspicion. Any patient with a history of trauma, presenting with headache, weakness, fluctuating changes in conscious level, or any combination of these features, should be investigated to rule out chronic subdural haematoma. Of various special investigations, carotid angiography proved to be the most useful. Simple burr hole evacuation was adequate treatment in 88 percent of the patients, only a minority requiring a more major neurosurgical procedure. The ultimate prognosis of patients with this condition is good, provided diagnosis is made early and treatment is prompt and adequate (AU)