Medical News - Part 3

In this patient, inadequate attention had been paid to warning signs. The initial heavy workload of the Bruce protocol (5 METs), infrequent blood pressure monitoring, continuation of the test despite a blunted blood pressure response, and physician inexperience may all have contributed to this catastrophe. Fortunately, the patient survived and underwent successful valve replacement Recent studies have improved our understanding of the patient with AS, and this knowledge will help prevent such events. …click here to read more

Physical Examination
Blood pressure was 150/90 mm Hg, regular pulse rate of 86, and respirations 16. He was a well developed, well nourished elderly white male. HEENT was normal, and the neck was supple without adenopathy Jugular venous pulse was non-distended with normal a and v waves. Carotids were slightly decreased in amplitude and had a slightly reduced upstroke velocity. No thrills were present, but there was a transmitted murmur from the base of the heart Lungs were clear to auscultation and percussion. The apical impulse was sustained but not displaced. A normal Sb soft S2, and A2, normal splitting of S2, no S4, no S3, and a grade 2/6 systolic ejection murmur with mid peaking at the right upper sternal border radiating to the neck were heard. …click here to read more

Effort syncope in patients with aortic stenosis (AS) has long been recognized in the medical literature. Recent guidelines regarding exercise testing by the American Heart Association and American College of Cardiology list moderate to severe AS as a contraindication for exercise testing. The following report illustrates the potential danger of exercising adult patients with AS. In addition, we review the mechanisms responsible for effort syncope in aortic stenosis and the value and limits of exercise testing in patients with AS, discuss how to monitor patients with AS during exercise testing, and define clinical situations in which exercise testing may be of value in AS. …click here to read more

The other expected complications of demyelinating diseases were observed, especially cutaneous and urinary infections. Yet, the absence of any thromboembolic events defies explanation. Bell et al reported on the clinical features of 167 patients with arigiographi-cally established pulmonary emboli. Thirty-two percent of the 167 patients were at bed rest of variable duration simulating the disability scales in our MS cases. Although they list 20 associated conditions with pulmonary embolism and their incidence in the 167 patients, patients with multiple sclerosis are not among the list Additionally, our multiple sclerosis cases have been immobilized and debilitated for more extensive periods, supposedly increasing the risk of deep venous thrombophlebitis and pulmonary embolism even further. …click here to read more

Finally, Tribe described autopsy data on 150 acute and chronic paraplegic patients. Among the 28 patients who expired in the acute period (defined as less than two months duration), six deaths were ascribed to pulmonary embolism, and in all six deep venous clots were found. In the remaining 122 cases described as chronic (greater than two months’ duration), autopsy failed to yield a single case of pulmonary embolism or deep venous thrombosis. A higher yield of thromboembolic disease would be expected in these chronic patients. Although these paraplegic patients were much more disabled than our MS population, the absence of clots is interesting. Thus, there is little comparison clotting data among non-MS neurologic conditions and MS. …click here to read more

Why pulmonary embolism and deep venous thrombophlebitis have not been observed here is obscure. Ellison et al in their extensive review of multiple sclerosis did not mention thromboembolic complications. Neither did McFarlin and McFarland, where they basically addressed epidemiology, etiology, and treatment. A total review of the multiple sclerosis literature in the past 20 years has failed to show a link between multiple sclerosis and pulmonary embolism. Conversely, there was no observation of any protective effect of multiple sclerosis on the peripheral venous system. Our sample size is large enough and the debility level severe enough to have expected some thrombotic events. Moreover, infectious complications were observed in our patients at an expected frequency. …click here to read more

The age, sex, and ethnic distributions of MS patients are shown in Table 2. The largest representation of patients was in the fourth decade, but significant numbers of patients were observed in other age groups up to age 59. The sex ratio is at variance with some texts and shows 3:1 predominance of females. Table 3 discloses the Kurtzke disability status scale. Among the 207 in whom a disability level was determined, 170 (82 percent) scored 6 or higher and 95 (46 percent) at 7 or above, indicating that a vast majority of the patients were incapacitated by their disease and considered to be at a higher risk for thromboembolism. …click here to read more