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Background: Acute pulmonary oedema (APOE) is a major health problem, leading to poor hospital and long-term outcomes. There is a relative paucity of studies describing prognosis of consecutive unsolicited patients diagnosed with APOE and hospitalized in internal medicine departments.Aims: To describe the clinical profile and outcome (in hospital and 1-year prognosis) of successive unselected patients with APOE, in a prospective observational study.Methods and Results: The study population included 150 consecutive unsolicited patients (90 men, 60 women; median age 75 years) with APOE all hospitalized in an internal medicine department, in a 900-bed care centre. Ischaemic heart disease (IHD), hypertension and diabetes were present in 85%, 70% and 52% of patients, respectively. The most common precipitating factors for APOE included high blood pressure (29%), rapid atrial fibrillation (29%), unstable angina pectoris (25%), infection (18%) and acute myocardial infarction (MI; 15%). Eighteen patients (12%) died in hospital, with 82% of these deaths attributed to cardiac pump failure. Predictors for an increased in-hospital mortality included: diabetes (P<0.05), orthopnoea (P<0. 05), echocardiographic finding of depressed global left ventricular systolic function (P<0.001), acute MI during hospital stay (P<0.001), hypotension/shock (P<0.05), and the need for mechanical ventilation (P<0.001). After a median hospital stay of 10 days, 132 patients were discharged home. The 1-year mortality was 40%. Only the presence of pleural effusion was found as a predictor for 1-year mortality.Conclusion: Most patients with APOE in this study are elderly, and have IHD, hypertension, diabetes and a previous history of APOE. The overall mortality is high (in-hospital, 12%: 1-year, 40%). Left ventricular dysfunction was associated with high in-hospital mortality, but not with long-term prognosis. [ABSTRACT FROM AUTHOR]

The ability to preserve myocardial structural and functional integrity during extended periods of total ischaemia has practical clinical significance. The role of endogenous catecholamines in the onset of irreversible damage in global ischaemia of the isolated rat heart was assessed by β-blockade or catecholamine depletion. The effects of propranolol and reserpine pretreatment on myocardial ultrastructure, function and metabolism were studied during normothermic ischaemic arrest (NICA) and reperfusion of the isolated working rat heart.β-blockade as well as catecholamine depletion resulted in an increase in the percentage of totally ischaemic hearts which recovered mechanically upon reperfusion. In these studies mechanical recovery during reperfusion was associated with reversal of ultrastructural ischaemic alterations, but without an improvement in mitochondrial function. These findings support the concept that failure of mitochondria to recover functionally upon reperfusion is not the cause of either irreversible mechanical failure or ultrastructural damage of the ischaemic myocardium. [ABSTRACT FROM PUBLISHER]

We present a young asymptomatic woman with splenomegaly and a large isolated splenic mass demonstrated by ultrasonography, 99mTc sulfur colloid, and gallium scintigraphy studies. Computerized tomography (CT) and three-phase 99mTc-labeled red blood cell imaging suggested a malignant lesion. Repeated sonographically guided fine needle aspiration (FNA) obtained only blood, suggesting the possible vascular nature of the tumor. Splenectomy established the diag-nosis of splenic hemangioma (SH) with marked sclerotic changes. We conclude from this case that 1) the sclerotic and cystic changes in the SH and the abdominal lymphadenopathy could explain why the three-phase red blood cell and CT scanning, respectively, suggested that the lesion was malignant rather than benign; 2) guided FNA of a splenic mass suspected to be hemangioma may he an additional safe and useful diagnostic procedure. Multiple aspirations yielding blood alone suggest hemangioma and may prevent an unnecessary operation. To the best of our knowledge, this is the first reported case in the literature of FNA of splenic hemangioma. [ABSTRACT FROM AUTHOR]

Aims: To assess the effectiveness and to identify predictors for successful electrical cardioversion (ECV) and maintenance of sinus rhythm, in long term follow up of patients with persistent (PAF) and chronic atrial fibrillation (CAF)., Methods and Results: Retrospective analysis of medical records of 68 patients with PAF or CAF, who underwent 91 cardioversions. ECV was successful in 86 attempts (94.5%). In obese (body mass index>30) and hypertensive patients (blood pressure >140/90 mm Hg), ECV was less successful in restoring sinus rhythm (p<0.05, p<0.021, respectively). Sinus rhythm was maintained more than half a year in 42 cardioversions (61%). Treatment with beta blockers prior to cardioversion and age younger than 75 were independent factors predicting long term success (p<0.013, p<0.034, respectively). Mild or moderate enlargement of left atrium (<6 cm) did not predict relapse of the arrhythmia. Second ECV was as or more effective than the first in 82.3% of patients that underwent more than one cardioversion., Conclusions: Conversion of atrial fibrillation by DC shock was found to be safe and effective procedure. Patients should be treated with beta blockers prior to cardioversion, if possible. Mild or moderate enlargement of left atrium is not contraindication to cardioversion. Recurrent cardioversions may be recommended.

Sarcoidosis is a systemic granulomatous disease of unknown etiology that involves many organs and has different clinical manifestation. We reviewed the clinical manifestations of sarcoid liver disease. Liver involvement in sarcoidosis can be serious and life-threatening, independent of its lung and other organ involvement.

Background: Properly administered, lumbar epidural analgesia provides adequate pain relief during labor and delivery, and is considered to be a safe procedure with limited complications. The prevalence of infection after lumbar epidural analgesia is negligible., Introduction: Infection of the sacroiliac joint, although very close to the pucture area, has never been reported as a procedure complication., Case: In this report, we describe a patient who experienced bacterial sacroiliitis a few days after lumbar epidural analgesia for labor. No portal of entry was identified, and we evoked a new potential risk factor that has never been proposed before, namely lumbar epidural analgesia., Conclusion: Sacroiliitis must be considered as a rare but serious complication of lumbar epidural analgesia.

As a teaching exercise, we used deductive reasoning and a quantitative analysis to convert a number of facts into a series of concepts to facilitate an understanding of integrative physiology and shed light on the composition of the different body fluid compartments. The starting point was the central need to regenerate ATP to perform biologic work. Because a large quantity of O2 must be delivered to cells at a sufficiently high concentration to aid its diffusion into mitochondria, approximately one third of the O2 in inspired air was extracted; this led to a P(CO2) in arterial blood of 40 mmHg (1 mmHg = 133.322 Pa). Blood flow to individual organs must be adjusted precisely to avoid having too low or too high a P(O2) in mitochondria--the latter augments the formation of reactive O2 species. The extracellular fluid (ECF) bicarbonate concentration (E(HCO3)) must be high to minimize H+ buffering by proteins. This high E(HCO3) sets the ECF concentrations of ionized calcium (Ca2+) and inorganic phosphate (HPO4(2-)) because of solubility issues. Three features defined the intracellular fluid (ICF) volume and composition. First, expelling monovalent anions minimized its mass (volume). Second, controlling the tissue P(CO2) ensured a relatively constant net valence on intracellular proteins. Third, the range of ICF Ca2+ concentrations must both induce regulatory signals and avoid Ca3(PO4)2 formation. All the above were incorporated into the integrated response that optimized the capacity for vigorous exercise.

Deficiencies of terminal complement components, particularly the latter ones, are often detected because of increased susceptibility to Neisserial infections. Herein we document the first report of C7 deficiency among a highly inbred Arab population living in the lower Galilee region of Israel. Both biochemical and molecular analysis were performed on samples from infected survivors and parents of children who succumbed to Neisserial infections in a 4-year period. Only the index case who suffered recurrent infections and a sibling who had not suffered an infection during the outbreak were found to be C7-deficient. The mutation was found to be the one previously described to be prevalent among Israeli Jews of Moroccan ancestry (mutation G1135C). The implications of this finding are discussed in the context of family pedigree, the protective effect of complement deficiency, and the clinical outcome., (Copyright 2002 Wiley-Liss, Inc.)

Gonadal hormones may affect homeostatic mechanisms regulating the cardiovascular system. We investigated this relationship at five different crucial hormonal time points along the menstrual cycle. Eight eumenorrheic healthy subjects underwent a battery of autonomic tests, hemodynamics, and volume-regulatory hormone measurements. Fluid-regulatory hormones, plasma renin activity, and aldosterone increased along the luteal phase (P = 0.003 and 0.02, respectively), whereas rest supine-corrected hematocrit declined in the course of the menstrual cycle (P = 0.001). Plasma norepinephrine decreased from 1.4 +/- 0.2 to 0.95 +/- 0.1 nmol/liter (P < 0.02) [early follicular (EF) to late follicular]. Thereafter, concentrations gradually returned to EF levels. Lf to Hf domain ratio (spectral analysis of electrocardiogram) showed a difference from that of norepinephrine. The cardiovagal baroreflex sensitivity increased significantly along the luteal phase (P = 0.04). The dose of isoproterenol required to increase heart rate (HR) 15 beats per minute was 0.19 +/- 0.04 microg during the EF time point, and it increased to 0.39 +/- 0.06 microg during the late luteal time point (P = 0.05). However, blood pressure, HR, and their responses to orthostatic stress remained unchanged. Fluctuations in the ovarian hormones along the menstrual cycle are associated with unchanged blood pressure and HR, despite the significant variations in the different homeostatic mechanisms regulating the cardiovascular system.

Background: Urinary tract complications in Crohn's disease are common but treatable, and often present diagnostic and therapeutic dilemmas., Purpose: To determine the incidence of urinary tract complications in patients with Crohn's disease in Israel and to report an experience over 15 years of patients with Crohn's disease, with the aim of illustrating the diverse patterns of presentation, and thereby broadening the approach to diagnosis and treatment., Methodology: Clinical and radiological findings of 312 patients with Crohn's disease were reviewed., Results: Simple cystitis was the most common problem, occurring in 51 patients. The problem seldom required hospitalization and was instead managed in the ambulatory setting. A review revealed that 22 patients with urinary tract complications required hospitalization. Six patients had ileovesical fistulas. In one patient, the colon was also affected. In another patient, radiological and endoscopic studies failed to identify the fistula, which was confirmed during surgery. All six patients were treated surgically. Four patients had ureteral obstructions and hydronephrosis, three of whom responded well to conservative treatment. In one patient, the affected ileal segment was resected. Four patients suffered from retroperitoneal abscess accompanied by urinary symptoms. Twelve patients developed right kidney stones. All of the patients suffered from long-standing Crohn's disease with bowel resection. Surprisingly, most of the severe complications occurred in men, although 70% of the patients were women., Conclusions: Based on these findings, urological complications are not rare in patients with Crohn's disease, and necessitate a high degree of diligence and periodic urological evaluation.

We present a case to illustrate the importance of emphasizing elementary physiology to deduce the basis for the acute onset of polyuria and hypernatremia. An imaginary consultation with Professor McCance is utilized to illustrate how a clinician-physiologist would have explained why these abnormalities developed and how they should have been treated. His approach began with a consideration of the most impressive abnormality. His analysis relied heavily on deductions and the anticipation of the expected responses to a stimulus in quantitative terms. The goals of therapy became evident after he performed mass balance calculations. Professor McCance would not understand why modern clinicians abandoned this form of analysis.

We report the case of a 35-year-old man who presented with fever, diarrhea, and a left abdominal mass. Diagnostic studies confirmed Crohn disease and revealed an abdominal mass obstructing the left ureter with hydroureter and hydronephrosis. The patient was successfully treated conservatively, with corticosteroids and mesalamine, A review of the literature indicates a predominance of right ureteral involvement in Crohn disease, associated with a high incidence of ileocecal disease. Most of these patients were treated surgically, with resection of ileocecal lesion and/or ureterolysis. Ureteral obstruction as a complication of Crohn disease is discussed, with emphasis on conservative treatment.

Bacteria-free verrucae, frequently termed "non-bacterial thrombotic endocarditis," have been recognized in autoimmune disorders as well as in neo-plastic diseases. The antemortem diagnosis of non-bacterial thrombotic endocarditis is rare, and most existing data result from postmortem examinations. In 3 prospective echocardiographic studies we found typical cardiac valvular lesions in patients with primary antiphospholipid syndrome, myelo-proliferative disorders, and solid malignant tumors. Cardiac lesions associated with these 3 different entities had common echocardiographic appearance and correlated positively with thromboembolic events. The possibility of common pathogenesis is suggested, and clinical significance is discussed.

Numerous studies have shown a beneficial effect of combination therapy with beta-blockers and calcium antagonists in patients with anginal syndrome and/or hypertension. However, because both agents exert a negative chronotropic effect, their combined use may cause bradyarrhythmias with resultant symptoms of cerebral, coronary, and systemic hypoperfusion. We describe our clinical experience with patients who had cardiovascular adverse drug reactions (CVADRs) with combination therapy. This prospective study included 26 patients who had CVADRs among 2,574 admissions during a 2-year period. The study group included 14 men and 12 women with a median age of 73 years. Various combinations of calcium antagonists and beta-blockers were associated with the CVADRs. The most frequent pharmacologic combination was diltiazem plus propranolol. The CVADRs were the cause for hospital admission in 10 patients, an associated cause in nine patients, and developed during hospitalization in seven patients. Cardiac bradyarrhythmias were found in 22 patients. These rhythm abnormalities resolved within 24 h after discontinuation of the offending drugs. Temporary transvenous pacemaker insertion was necessary in only one patient with complete atrioventricular block. Twenty-two patients recovered, two patients died of pump failure not associated with CVADRs, and in two patients, the CVADRs contributed to the patients' death. CVADRs are not uncommon in elderly patients with ischemic heart disease and/or hypertension treated with the concomitant use of calcium antagonist and beta-adrenergic blocking drugs. Use of calcium antagonist plus beta-blocker may unpredictably cause serious hemodynamic events, marked suppression of sinus node activity, and prolongation of atrioventricular conduction in some patients. Enhanced therapeutic monitoring may be warranted when calcium antagonists are combined with beta-blockers.

The development of chylous ascites following abdominal surgery is an infrequent yet alarming complication. We present a patient in whom chylous ascites was diagnosed 6 days after a distal splenorenal shunt. Ten days following bed rest, sodium restriction, and a low-fat diet with medium-chain triglyceride supplementation the ascites resolved.

Objectives: To describe the clinical profile and hospital outcome of successive unselected patients with pulmonary edema hospitalized in an internal medicine department., Design: Prospective, consecutive, unsolicited patients diagnosed with pulmonary edema., Setting: An internal medicine department in a 900 tertiary care center., Patients: A total of 150 consecutive unselected patients (90 males, 60 females; median age, 75 yrs)., Results: Ischemic heart disease, hypertension, various valvular lesions and diabetes mellitus were present in 85%, 70%, 53%, and 52% of patients, respectively. Acute myocardial infarction at admission was observed in 15% of patients. The most common precipitating factors associated with the development of pulmonary edema included: high blood pressure (29%), rapid atrial fibrillation (29%,) unstable angina pectoris (25%), infection (18%), and acute myocardial infarction (15%). Twenty-two patients (15%) were mechanically ventilated. Eighteen patients (12%) died while in the hospital, and the cause of death was cardiac pump failure in 82%. The median hospital stay was 10 days. Predictors for increase rate of in-hospital mortality included: diabetes (p<.05), orthopnea (p<.05), echocardiographic finding of moderate-to-severely depressed global left ventricular systolic function (p<.001), acute myocardial infarction during hospital stay (p<.001), hypotension/shock (p<.05), and the need for mechanical ventilation (p<.001)., Conclusions: Most patients with pulmonary edema in the internal medicine department are elderly, having ischemic heart disease, hypertension, diabetes, and a previous history of pulmonary edema. The overall mortality is high (in-hospital, 12%) and the predictors associated with high in-hospital mortality are related to left ventricular myocardial function. The long median hospital stay (10 days) and the need for many cardiovascular drugs, impose a considerable cost in the management and health care of these patients.

A 63-year-old man with seronegative rheumatoid arthritis developed acute pancreatitis, severe hepatitis, and sensorimotor polyneuropathy after receiving 150 mg of intramuscular aurothioglucose (gold). Positive lymphocyte transformation test to gold indicated a cell mediated hypersensitivity to the drug, while multiple investigations ruled out other underlying causes for his illness. After cessation of gold therapy a complete recovery occurred.

We report a case of acute chylous ascites secondary to acute biliary pancreatitis, the first such case reported in the literature. Surprisingly, chylous ascites was detected during elective cholecystectomy. The pathogenesis and management of this problem is discussed.