Fever and urticaria in acute giardiasis.

Travelers' diarrhea afflicts some 250 million people yearly. A number of etiologic agents have been identified, including bacteria, viruses, and parasites. Giardia lamblia is one of the pathogens clearly associated with this syndrome. Typical symptoms of giardiasis that include abdominal bloating and cramps are well known, whereas urticaria has rarely been associated with this illness. An American tourist developed acute giardiasis accompanied by urticaria and high fever. No other pathogens were identified, and response to metronidazole therapy was prompt. Giardiasis should be included in the differential diagnosis of acute urticaria and fever in the traveler.

Calf muscle adaptation to peripheral vascular disease.

130 muscle biopsies were taken from the gastrocnemius of 82 patients with different degrees of peripheral vascular disease (PVD) and 19 normal controls for histochemical analysis, and 30 patients and 7 controls for biochemical analysis of "aerobic" and "anaerobic" enzymes. The results showed that the gastrocnemius of patients with PVD did not adapt by increasing its "aerobic" potential as previously suggested. Histochemical studies showed that the cross-sectional area of both Type 1 and Type 2 muscle fibres became smaller than those from age-matched controls in the presence of PVD, and in some cases biopsies from both legs confirmed that this trend was greater in those limbs with increasing evidence of PVD. There is also some evidence to suggest a decrease in absolute capillary numbers per muscle fibre. The biochemical assays confirmed decreased levels of aerobic enzymes with increasing evidence of PVD as judged by ankle systolic pressure, and those patients with intermittent claudication showed some evidence of increased anaerobic enzyme levels in comparison to both the normal controls and those with rest pain. Patients with PVD do not adapt to ischaemia/anoxia by increasing their aerobic capability, but show signs of muscle atrophy probably due to reduced mobility. Training regimes may benefit patients with intermittent claudication by reversing these changes.

Comparison of frequencies of atrial fibrillation after coronary artery bypass grafting with and without the use of cardiopulmonary bypass.

This study compared the incidence of postoperative atrial fibrillation in a group of 34 patients undergoing coronary artery bypass graft surgery without the use of cardiopulmonary bypass and cardioplegia with a control group of 747 patients undergoing coronary artery bypass graft surgery using cardiopulmonary bypass and standard cardioplegia. A trend toward a lower incidence of postoperative atrial fibrillation was found in the group that underwent coronary artery bypass graft surgery without the use of cardiopulmonary bypass (n = 0.06).

Systemic and left ventricular responses to exercise stress in asymptomatic patients with valvular aortic stenosis.

Patients with heart disease may have myocardial ischemia or left ventricular (LV) dysfunction without symptoms. The exercise responses of 14 asymptomatic patients with valvular aortic stenosis (AS) were studied using treadmill testing, thallium-201 scintigraphy and radionuclide angiography. Compared with age- and gender-matched control subjects, patients with AS demonstrated reduced exercise tolerance (10.7 +/- 2.5 vs 13.3 +/- 4.2 min; p = 0.06) and maximal oxygen consumption (26.7 +/- 6.3 vs 36.3 +/- 9.5 ml O2/min/kg; p = 0.004) associated with decreased peak systolic blood pressure response to exercise (177 +/- 18 vs 214 +/- 42 mm Hg; p less than 0.004). Ten of 14 patients developed ST-segment depression during exercise, only 3 of whom had reversible thallium defects. Patients with AS tended to have greater LV ejection fractions at rest (65 +/- 11 vs 58 +/- 7; p = 0.08) and significantly decreased early peak filling rates (4.8 +/- 1.3 vs 6.1 +/- 0.6 stroke volume/s; p = 0.003) compared with those of control subjects. During maximal supine exercise, patients with AS had less of an increase in ejection fraction (2 +/- 9 vs 15 +/- 7%; p less than 0.001) associated with a decrease in end-diastolic (-7 +/- 15 vs +5 +/- 16%; p = 0.06) and stroke (-6 +/- 17 vs +30 +/- 13%; p less than 0.001) volumes from baseline measurements.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrastructural and capillary adaptation of gastrocnemius muscle to occlusive peripheral vascular disease.

The effect of chronic occlusive peripheral vascular disease (PVD) on the histochemistry and capillarity of the gastrocnemius muscle was studied in 129 biopsies taken from 93 subjects. Sixty-three patients underwent biopsy during surgical procedures, and data related to walking distance and ankle systolic pressure. Thirty biopsies taken from normal subjects post mortem served as a control group, and data were analyzed for fiber type distribution, fiber area, fiber type grouping, and fiber capillarity. Fiber type distribution did not alter significantly between the patients with PVD and the control group, but the mean fiber area of the type 1 fiber in male patients with intermittent claudication (IC) was reduced when compared to that in age-matched controls (4608 +/- 1181 mu 2, IC +/- 1 SD; 5795 +/- 1771 mu 2, controls +/- 1 SD) (P less than 0.05). When bilateral biopsies were taken from the gastrocnemii of patients with unilateral occlusions, the type 2 fibers in the diseased leg were significantly smaller than fibers of the control group (2821 +/- 953 mu 2, IC +/- 1 SD; 4318 +/- 1504 mu 2, controls +/- 1 SD) (P less than 0.02). Fiber type grouping, evidence of denervation and reinnervation of muscle, appeared to be more common in patients with more severe limb ischemia. Overall capillary numbers did not appear to alter with degree of ischemia, but fiber shrinkage appeared to compensate for any loss of capillaries in the more ischemic muscle. These data suggest that the limb of the untrained patient with IC does not adapt to ischemia by adjusting its exercise capacity but merely shows evidence of disuse. These adaptations suggest that there may be much to be gained by nonsurgical methods of treating IC.

Smoking, ignorance, and peripheral vascular disease.

The effect of the surgeon's advice to give up smoking was studied in a group of 43 patients with peripheral vascular disease (PVD), using blood carboxyhemoglobin levels to detect deception. Only seven of 40 patients (17.5%) actually stopped smoking, but the remainder appeared fairly honest in reporting their continued habits. Few patients were aware of the possible harmful effect of smoking on the peripheral arteries. The 43 patients with PVD who smoked had significantly higher carboxyhemoglobin levels than a group of 25 smokers without PVD although their cigarette consumption was the same. This suggests that carboxyhemoglobin levels may provide a better indication of the risk of smoking than overall cigarette consumption alone in the development of PVD.

Traumatic intracardiac communication: detection by color flow mapping.

A previously healthy 20-year-old man underwent emergency surgery for repair of a right ventricular free wall laceration that was the result of a knife wound. A systolic murmur was first heard 1 month later, and two-dimensional echocardiography and color flow mapping demonstrated a communication between the left and right ventricle in the region of the membranous septum. The visualized turbulent flow was consistent with a ventriculoseptal defect but also appeared to extend posteriorly into the left atrium in a direct line with the septal communication. At cardiac catheterization the calculated left-to-right shunt was 1.2:1.

Oxygen tension of the skin of ischemic legs.

Using a Kontron Roche Transcutaneous Oxygen Monitor, we measured oxygen tension on the skin of the legs at three sites in patients with peripheral vascular disease and group of controls. Significant decreases in oxygen tension occurred in the patient groups, which correlated well with ankle systolic pressure, with differences between those with claudication and those with rest pain. These results suggest that in limbs with claudication, significant skin hypoxia may exist during rest in spite of reportedly normal skin and muscle blood flow. The progressive decrease in skin oxygen tension down a limb with occlusive vascular disease may play a significant role in skin healing.

Glycosylated haemoglobin in non-diabetic peripheral vascular disease.

Glycosylated haemoglobin (Hb A1c) was measured in 20 patients with severe peripheral vascular disease (P.V.D.) and 12 controls. Levels were significantly higher in those with P.V.D. and this may be due to mild carbohydrate intolerance frequently exhibited by this group of patients.

The surgical value of community hospitals: a closer look.

To assess and compare the safety and efficiency of a surgical unit at a District General Hospital and a Community Hospital for elective cold surgery. A retrospective survey was made using regional computer Hospital Activity Analysis data and monthly audit meeting records of all inpatients having selected elective general surgical operations on one consultant's firm over a period of one year, at Torbay Hospital, Torquay, (DGH) and Newton Abbot Hospital, Newton Abbot (CH). All inpatients and day cases admitted under CACC from April 1, 1987, until March 31, 1988, were studied comparing mortality, morbidity and efficiency for comparable elective surgical procedures. A postal questionnaire to assess patient satisfaction with surgical care at both hospitals was included in the study. 350 patients underwent elective surgical procedures at the DGH and 380 patients underwent similar procedures at the CH. There was no significant increase in mortality and morbidity at the CH, which was preferred by most patients for routine surgical operations. The Community Hospital unit was found to be satisfactory and more efficient for routine elective surgery as determined from the above parameters and the patients themselves.

Impotence: relevance and assessment in the surgical patient.

Two simple methods of assessing the presence and likely cause of impotence are described. The mechanism of sexual dysfunction is discussed with particular relevance to the surgical patient.

PTFE (Goretex) femoropopliteal reconstruction for limb salvage.

We present the results of the use of polytetrafluoroethylene (PTFE, Goretex) grafts for limb salvage in 20 cases of femoropopliteal or more distal arterial reconstruction. There appears to be no relationship between graft survival and 'run-off' or the overall disease state of the vessels. Cumulative graft patency was almost 50% at 6 months, which is in contrast with higher patency rates reported from other countries.

Below knee femoropopliteal bypass in severe ischaemia: results using EXS Dacron and human umbilical vein.

This paper reports our preliminary experience using EXS Dacron for infrageniculate femoropopliteal grafts in elderly patients, the majority (78%) suffering critical ischaemia. A comparison is made with human umbilical vein grafts (HUV). Ninety patients (mean age 69 years) with 92 grafts (42 EXS, 50 HUV) were followed up using ultrasound imaging to detect patency (median follow up 26 weeks (range 1-292)). Two and one year cumulative survivals were 57% and 80% for EXS Dacron and 39% and 48% for HUV respectively. Early failure of HUV grafts accounted for most but not all of the difference in survival (P = 0.0012, Wilcoxon Breslow). Graft kinking was not seen in EXS grafts and in only 2 HUV. Poor calf vessel run off was related to early graft occlusion (P = 0.01; Savage, Mantel Cox). This preliminary experience with EXS Dacron is encouraging and suggests the need for a formal randomised study.

Non-surgical management of peripheral vascular disease: a review.

Although the outlook for a pronounced improvement in the ischaemic limb that cannot be surgically treated remains bleak, cessation of smoking, encouragement of exercise, and the withdrawal of vasoconstricting agents may give some symptomatic relief. There is little evidence that vasodilators or antiplatelet agents have much to offer.

Antithrombotic therapy in the primary and secondary prevention of coronary-related death and infarction: focus on gender differences.

Much of our understanding of the role of antithrombotic therapy for postmyocardial infarction patients comes from studies which often included few or no women. Despite this shortcoming there are data available which identify gender differences in risk factors, presentation, natural history and treatment results for myocardial infarction. The use of anticoagulants and antiplatelet agents in the prevention and management of myocardial infarction has evolved over 30 years of investigation. The major randomized, controlled and blinded studies of antithrombotics and myocardial infarction are reviewed, with special emphasis on the female population.