Sandor A. Friedman

Arterial thrombosis in essential thrombocythemia

The course of essential thrombocythemia has been observed in ten patients, ages 46 to 83, of whom nine were followed for a period of 4 months to 9 years. In contrast to the experience with essential thrombocythemia recorded in the literature, manifestations of arterial thrombosis were far more common than hemorrhage. In six of the ten patients, the presenting complaints were ascribable to incipient gangrene of the toes and several of these patients additionally developed occlusion of tibial and larger arteries while under our observation. All patients with incipient gangrene showed marked clinical improvement accompanying busulfan-induced reduction and normalization of the platelet count. Relapses in five patients after 2 to 87 months responded well to retreatment with busulfan. No patient has shown evolution to another myeloproliferative disorder. Essential thrombocythemia should be considered in the differential diagnosis of occlusive arterial disease.

The Diagnosis of Myocardial Infarction by Computer-Derived Protocol in a Municipal Hospital

The evaluation of an emergency room patient with acute chest pain is often difficult. Recently, computers have been employed to develop protocols for identifying which patients are likely to have acute myocardial infarctions and to benefit, therefore, from admission to a relatively scarce coronary care unit bed. We have tested the latest computer-derived instrument in a municipal hospital and found it to be less reliable than the clinical judgement of physicians.

Raynaud's Phenomenon in Hypothyroidism

Two patients with Raynauds phenomenon were found to be hypothyroid and their symptoms disappeared with thyroid replacement therapy. Vascular reactivity studies in one patient demonstrated decreased vasomotor tone after therapy. Raynauds phenomenon may be an expression of altered autonomic function in hypothyroidism.

Paradoxical embolism secondary to tricuspid valve endocarditis

closure and was more likely to result in changes in heart rate and pressures. We now only attempt to cross through the major orifice. In patient 3, ascending aortic angiography was performed to quantitate AR before (1+) and after (3+) insertion of the probing catheter. We were surprised that this increased magnitude of AR was not associated with important changes in aortic and PCW pressures. In all 4 patients the procedure was tolerated without complication. No symptoms or hemodynamic deterioration occurred despite the probing catheter remaining in the left ventricle for up to 10 minutes. Fluoroscopic time to cross the prosthesis varied between 1 and 5 minutes. Hemodynamic changes noted with the probing catheter across the aortic prosthesis included consistent mild elevation of PCW pressure. Aortic pressure and heart rate did not consistently change. These alterations did not appear to be of sufficient magnitude to interfere with evaluation of aortic valve systolic and mitral valve diastolic function. This technique is easily performed without apparent risk. It allows measurement of LV pressure and permits evaluation of the aortic valve prosthesis and mitral valve. Although AR is created by the probing catheter across the valve, it appears to be less severe than that created with larger left heart catheters. We believe that we were able to accurately assess aortic valve systolic gradients and prosthetic valve obstruction. Unfortunately, the 4Fr catheter is too small to allow sufficient contrast injection for LV angiography. An aortic root injection with a separate catheter can opacify the left ventricle adequately for evaluation of contractile function and mitral valve competence. Although our experience is limited to a few cases, it demonstrates a useful alternative to other techniques for invasive ass e s s m e n t of aortic tilting disc prosthetic valve function. This system may also be applicable to evaluation of certain other mechanical valves in the aortic position and we have used it successfully in some cases of severe native valve aortic stenosis.

Common manifestations of degenerative arterial disease.

The major focus of preventive medicine in the aged must be on the clinical consequences of peripheral arteriosclerosis rather than the disease process itself. Treating risk factors may be of some limited benefit. However, of most crucial importance is careful attention to premonitory symptoms and the state of the peripheral pulses including the abdominal aorta.

Diabetic Osteopathy: Report of a Relentlessly Progressive Case, with Clinico-Pathologic Correlations

A case is presented of diabetic neuropathy with progressive, persistent destruction of the skeletal structure of one foot despite immobilization. Pathologic examination revealed only bland necrosis of the bone and cartilage. The pathogenesis of diabetic osteopathy requires further clarification.