Melvyn H. Schreiber

Severe Pulsus Alternans Associated with Primary Myocardial Disease in Children Observations on Clinical Features, Hemodynamic Findings, Mechanism, and Prognosis

Five children, including two siblings, with clinically similar primary myocardial disease, were studied. One of the siblings expired 3 years after the onset of symptoms, and autopsy showed features of “cardiovascular collagenosis (endocardiomyopathy).” Moderate-to-severe pulsus alternans was present in all cases and persisted even after control of cardiac failure and return to moderate physical activity. No electrical alternans or bigeminy was observed.Cardiac catheterizations were performed on all patients. Left ventricular volume was radiographically determined in the siblings. Left ventricular end-diastolic volume was calculated as greater, and end-systolic volume smaller, for large beats as compared with small beats. Though alternating, end-diastolic volume was abnormally large, preceding both small and large beats. End-diastolic pressure alternated in the same way. Beat to beat (R-R) interval, alternating by as much as 0.09 second, was equalized by pacing in the right atrium and right ventricle, with persistence of pulsus alternans to a lesser degree. Isovolumetric contraction time was prolonged preceding small beats in spite of the large preceding end-diastolic volumes.The data appear to be consistent with Starlings law but suggest that impaired contractility, possibly due to alternate deletion of contractile elements, is an additional etiological factor.

Radiological evaluation of prosthetic fit in below-the-knee amputees

Fourteen artificial limbs in eight adult patients with below the knee amputations were evaluated for prosthetic fit by several radiological parameters. The best objective means of evaluation of prosthetic adequacy is piston action.

Magnetic resonance imaging in patients with unstable angina: Comparison with acute myocardial infarction and normals☆

The role of magnetic resonance imaging in characterizing normal, ischemic and infarcted segments of myocardium was examined in 8 patients with unstable angina, 11 patients with acute myocardial infarction, and 7 patients with stable angina. Eleven normal volunteers were imaged for comparison. Myocardial segments in short axis magnetic resonance images were classified as normal or abnormal on the basis of perfusion changes observed in thallium-201 images in 22 patients and according to the electrocariographic localization of infarction in 4 patients. T2 relaxation time was measured in 57 myocardial segments with abnormal perfusion (24 with reversible and 33 with irreversible perfusion changes) and in 25 normally perfused segments. T2 measurements in normally perfused segments of patients with acute myocardial infarction, unstable angina and stable angina were within normal range derived from T2 measurements in 48 myocardial segments of 11 normal volunteers (42 +/- 10 ms). T2 in abnormal myocardial segments of patients with stable angina also was not significantly different from normal. T2 of abnormal segments in patients with unstable angina (64 +/- 14 in reversibly ischemic and 67 +/- 21 in the irreversibly ischemic segments) was prolonged when compared to normal (p less than 0.0001) and was not significantly different from T2 in abnormal segments of patients with acute myocardial infarction (62 +/- 18 for reversibly and 66 +/- 11 for irreversibly ischemic segments). The data indicate that T2 prolongation is not specific for acute myocardial infarction and may be observed in abnormally perfused segments of patients with unstable angina.(ABSTRACT TRUNCATED AT 250 WORDS)

Rectal diverticulosis: a case report and review of the literature.

The occurrence of rectal diverticulosis is rare. We report the incidental finding of a large rectal diverticulum in a patient receiving an air-contrast barium enema. The presence of uncomplicated rectal diverticulosis is probably of little clinical significance. However, there can be associated complications such as inflammation and perforation, and potential confusion with rectal carcinoma.

Traumatic Diaphragmatic Hernia into the Pericardium: Verification of Diagnosis by Computed Tomography

Computed tomography (CT) is a useful modality in the evaluation of mediastinal abnormalities and in the assessment of mediastinal masses for fat content. A case of posttraumatic herniation of the omentum and large bowel into the pericardial sac is presented. The mediastinal configuration, depicted on a CT scan, is thought to be diagnostic of this extremely rare abnormality.

Left ventricular aneurysm in short axis: a comparison of magnetic resonance, ultrasound and thallium-201 SPECT images.

Short axis magnetic resonance images of a left ventricular aneurysm were compared to similar views obtained by echocardiography and by thallium-201 single photon emission computed tomography. Images of the dyskinetic left ventricular apex and the contractile left ventricular base were analyzed and compared. Unlike the previously reported orthogonal plane magnetic resonance images, short axis imaging provided representative and quantitative information in views comparable to those obtained by standard noninvasive imaging techniques. These data indicate that short axis magnetic resonance imaging is capable of identifying and sizing the aneurysmal and the residual segments of the left ventricle. The findings may be of prognostic value in patients with left ventricular aneurysm.

Congenital idiopathic hypertrophic subaortic stenosis associated with a phenotypic Turner's syndrome☆

Abstract A case of idiopathic hypertrophic subaortic stenosis in a girl with phenotypic Turners syndrome is reported. The coincidence of these rare anomalies, reported only once before, is unlikely to occur by chance. Essential clinical features leading to early diagnosis of idiopathic hypertrophic subaortic stenosis in infancy are presented. Surgical treatment when the child weighed 15.9 kg gave satisfactory results at 18-month follow-up study.

Cardiac Volume in Normal Children and Adolescents Its Application to Patients with Rheumatic Mitral Insufficiency

Cardiac volume was determined by a simplified Rohrer-Kahlstorf method in 305 healthy children and adolescents. The ages ranged from birth to 19 years. Height and weight were comparable with normal growth standards. Race, sex, age, height, weight, and body surface area were studied for their value in predicting cardiac volume. Cardiac volume was different in males and females (p < 0.005) and was more closely predicted by weight than by body surface area. In this study body weight has been used as a single predictor of cardiac volume for both sexes. Normal values are presented and the limitations of the technique discussed.Serial cardiac volume plotted against weight and cardiothoracic ratio plotted against time were correlated with the clinical course in 27 children with pure rheumatic mitral insufficiency. Cardiac volume was found to be superior to the cardiothoracic ratio in reflecting the severity and prognosis of mitral insufficiency. After the cardiac volume had reached a level of 1,100 to 1,300 ml, the course was progressively downhill in 10 adolescents in the absence of evidence of rheumatic activity in most cases.That the course of rheumatic mitral insufficiency is essentially volume-dependent is a phenomenon of great interest which may be used to assess the severity of mitral regurgitation and its future course.

ANGIOGRAPHIC FINDINGS IN ARTERIOVENOUS FISTULAS FOLLOWING LUMBAR DISK SURGERY

The development of an arteriovenous fistula between the aorta and its iliac branches and the vena cava and its iliac tributaries is an uncommon complication of surgery for herniated intervertebral disk. The diagnosis is usually obvious by physical examination. Retrograde femoral abdominal aortography accurately displays the anatomic character and the location of the communication.Three cases are reported.

Alumni perceptions of adequacy of training in diagnostic radiology.

Former residents who completed an accredited university radiology residency between 1953 and 1983 were surveyed using a written questionnaire. Seventy-five percent responded with opinions concerning their satisfaction with the various aspects of their training, including whether the program had met the specific needs of their practice. Most were satisfied with their training. Many believed the program should offer formal training in nonclinical areas such as quality control, equipment selection, administration, economics, and contract negotiations. Nearly all (96%) believed they had been adequately prepared for the Board examination. The majority (75%) believed a postgraduate clinical year was important prior to entering a radiology residency. We believe the written survey is a useful means for gathering data regarding adequacy of residency training. With the current interest in residency program curricula, such data may be useful in the dynamic process of structuring residency programs.