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Noninvasive assessment of load reduction in patients with asymptomatic aortic regurgitation
Bacteremia
Continued
Although over-all cardiac performance may remain normal in patients with left ventricular volume overload from valvular regurgitation, impairment of myocardial function may occur and remain undetected by currently accepted methods of assessing ventricular performance. We found that the preoperative end-systolic volume could accurately predict patients at high risk for perioperative cardiac death or impaired ventricular function after valve replacement. Neither preoperative ejection fraction nor end-diastolic volume correlated as well with surgical outcome.
Borow KM, Green LH, Mann T. Sloss LJ, Braunwald E, Collins JJ Jr, Cohn L, Grossman W: End-systolic volume as a predictor of postoperative left ventricular performance in volume overload from valvular regurgitation. Am J Med 1980; 68:855-863.
Valvular regurgitation Left ventricle Myocardial function Cardiac performance Volume overload
Nitroglycerin
Wall
stress
Afterload
on page A29
The effect of nitroglycerin on wall stress was determined in 10 normal subjects and eight asymptomatic subjects with aortic regurgitation and normal left ventricular and circulatory function. Peak and end-systolic wall stress was estimated by noninvasive echocardiographic technique. At rest, despite larger left ventricular dimensions in those with aortic regurgitation, peak systolic wall stress was similar to that in normal subjects. In contrast, end-systolic wall stress was higher in those with aortic regurgitation. Following the administration of nitroglycerin, subjects with aortic regurgitation had larger reductions in left ventricular end-diastolic and end-systolic dimensions than did normal subjects, despite similar changes in blood pressure. Normalization of end-systolic wall stress resulted as well as peak systolic wall stress below normal in the subjects with aortic regurgitation. We conclude that (1) nitroglycerin offers an effective means of rapidly reducing afterload in asymptomatic aortic regurgitation; (2) left ventricular dimensional changes are larger in those with aortic regurgitation than in normal subjects. Thus, unloading therapy may help to protect the left ventricle in this disorder.
Wilson JR. Reichek N, Hirshfeld J, with the technical assistance of Keller CA: Noninvasive assessment of load reduction in patients with asymptomatic aortic regurgitation. Am J fvled 1980; 88: 684-674.
Aortic regurgitation Left ventricle
Nine patients with hypoglycemia (mean serum glucose of 22 mg/dl) associated with over-’ whelming bacterial sepsis are described. Clinical disease included pneumonia and cellulitis, in three patients, no focus of infection was apparent. Altered mental status, metabolic acidosis, leukopenia. abnormal clotting studies and bacteremia were common features. In five of the nine patients another possible metabolic cause for hypoglycemia was present (alcoholism in four) although none had been observed to be hypoglycemic on previous_ hospitalizations. Streptococcus pneumoniae and Hemophilus influenzae, type b, were the most common pathogens, with an over-all mortality of 67 per cent. In vitro incubation of bacteria with serum did not increase the rate of breakdown of glucose, suggesting that the hypoglycemia is an in vivo occurrence, probably relating to depleted glycogen stores and impaired gluconeogenesis. Hypoglycemia is an important sign of overwhelming sepsis that may be more common than has previously been recognized.
Sepsis
Sixty-Seven episodes Of gram-negative bacteremia in granulocytopenic patients with cancer were evaluated to correlate prognostic determinants of patient recovery. Twenty-seven of 29 patients (93 per cent) with an increase in granulocyte count of more than or equal to lOO/pl over the 14 days following documented bacteremia recovered whereas 21 of 38 patients (55 per cent) wfth no appreciable increase in granulocytes recovered. In patients with no spontaneous increase in granulocytes, the susceptibility of the infecting organism to the empiric antibiotic regimen was of major importance. None of four patients responded when the pathogen was resistant to both empiric antibiotics, six of 14 (44 per cent) patents responded when the pathogen was susceptible to one antibiotic, and 15 of 20 (75 per cent) patients responded when the pathogen was susceptible to both (p <0.025). Patients with gram-negative bacteremia and persistent granulocyfopenia will often respond to antibiotics alone when appropriate antibiotic therapy is initiated promptly. Granulooyte transfusions may not be essential for recovery unless there is evidence of early inadequate response.
Hypoglycemia
Miller SI, Wallace RJ, Jr, Musher DM, Septimus EJ, Kohl S, Baughn RE: Hypoglycemia as a manifestation of sepsis. Am J Med 1980; 88: 649-654.
Cancer Antibiotic combinations
Love LJ, Schimpff SC, Schiffer CA, Wiernik PH: Improved prognosis for granulocytopenic patients with gram-negative bacteremia. Am J Med 1980; 68: 643-648.
Gram-negative bacteremia Granuiocytopenia Empiric antibiotics Granuiocyte transfusions
Continued
Although over-all cardiac performance may remain normal in patients with left ventricular volume overload from valvular regurgitation, impairment of myocardial function may occur and remain undetected by currently accepted methods of assessing ventricular performance. We found that the preoperative end-systolic volume could accurately predict patients at high risk for perioperative cardiac death or impaired ventricular function after valve replacement. Neither preoperative ejection fraction nor end-diastolic volume correlated as well with surgical outcome.
Borow KM, Green LH, Mann T. Sloss LJ, Braunwald E, Collins JJ Jr, Cohn L, Grossman W: End-systolic volume as a predictor of postoperative left ventricular performance in volume overload from valvular regurgitation. Am J Med 1980; 68:855-863.
Valvular regurgitation Left ventricle Myocardial function Cardiac performance Volume overload
Nitroglycerin
Wall
stress
Afterload
on page A29
The effect of nitroglycerin on wall stress was determined in 10 normal subjects and eight asymptomatic subjects with aortic regurgitation and normal left ventricular and circulatory function. Peak and end-systolic wall stress was estimated by noninvasive echocardiographic technique. At rest, despite larger left ventricular dimensions in those with aortic regurgitation, peak systolic wall stress was similar to that in normal subjects. In contrast, end-systolic wall stress was higher in those with aortic regurgitation. Following the administration of nitroglycerin, subjects with aortic regurgitation had larger reductions in left ventricular end-diastolic and end-systolic dimensions than did normal subjects, despite similar changes in blood pressure. Normalization of end-systolic wall stress resulted as well as peak systolic wall stress below normal in the subjects with aortic regurgitation. We conclude that (1) nitroglycerin offers an effective means of rapidly reducing afterload in asymptomatic aortic regurgitation; (2) left ventricular dimensional changes are larger in those with aortic regurgitation than in normal subjects. Thus, unloading therapy may help to protect the left ventricle in this disorder.
Wilson JR. Reichek N, Hirshfeld J, with the technical assistance of Keller CA: Noninvasive assessment of load reduction in patients with asymptomatic aortic regurgitation. Am J fvled 1980; 88: 684-674.
Aortic regurgitation Left ventricle
Nine patients with hypoglycemia (mean serum glucose of 22 mg/dl) associated with over-’ whelming bacterial sepsis are described. Clinical disease included pneumonia and cellulitis, in three patients, no focus of infection was apparent. Altered mental status, metabolic acidosis, leukopenia. abnormal clotting studies and bacteremia were common features. In five of the nine patients another possible metabolic cause for hypoglycemia was present (alcoholism in four) although none had been observed to be hypoglycemic on previous_ hospitalizations. Streptococcus pneumoniae and Hemophilus influenzae, type b, were the most common pathogens, with an over-all mortality of 67 per cent. In vitro incubation of bacteria with serum did not increase the rate of breakdown of glucose, suggesting that the hypoglycemia is an in vivo occurrence, probably relating to depleted glycogen stores and impaired gluconeogenesis. Hypoglycemia is an important sign of overwhelming sepsis that may be more common than has previously been recognized.
Sepsis
Sixty-Seven episodes Of gram-negative bacteremia in granulocytopenic patients with cancer were evaluated to correlate prognostic determinants of patient recovery. Twenty-seven of 29 patients (93 per cent) with an increase in granulocyte count of more than or equal to lOO/pl over the 14 days following documented bacteremia recovered whereas 21 of 38 patients (55 per cent) wfth no appreciable increase in granulocytes recovered. In patients with no spontaneous increase in granulocytes, the susceptibility of the infecting organism to the empiric antibiotic regimen was of major importance. None of four patients responded when the pathogen was resistant to both empiric antibiotics, six of 14 (44 per cent) patents responded when the pathogen was susceptible to one antibiotic, and 15 of 20 (75 per cent) patients responded when the pathogen was susceptible to both (p <0.025). Patients with gram-negative bacteremia and persistent granulocyfopenia will often respond to antibiotics alone when appropriate antibiotic therapy is initiated promptly. Granulooyte transfusions may not be essential for recovery unless there is evidence of early inadequate response.
Hypoglycemia
Miller SI, Wallace RJ, Jr, Musher DM, Septimus EJ, Kohl S, Baughn RE: Hypoglycemia as a manifestation of sepsis. Am J Med 1980; 88: 649-654.
Cancer Antibiotic combinations
Love LJ, Schimpff SC, Schiffer CA, Wiernik PH: Improved prognosis for granulocytopenic patients with gram-negative bacteremia. Am J Med 1980; 68: 643-648.
Gram-negative bacteremia Granuiocytopenia Empiric antibiotics Granuiocyte transfusions