Arch Intern Med
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Case Reports
Cardiac assessment for patients undergoing noncardiac surgery. A multifactorial clinical risk index.
In this article, we describe a multifactorial cardiac risk index that can be used to assess patients undergoing noncardiac surgery. The index is a modified version of an index that was previously generated by Goldman and coworkers on a set of 1001 consecutive patients and prospectively validated in our clinical setting (a general medical consultation service in a large teaching hospital) on 455 patients. We present a Bayesian approach to assessing cardiac risks by converting average risks for patients undergoing particular surgical procedures (pretest probabilities) to average risks for patients with each index score (posttest probabilities). A simple nomogram is presented for performing such a calculation.
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Case Reports
Milk-alkali syndrome in patients treated with calcium carbonate after cardiac transplantation.
Heart and heart-lung transplant recipients at Stanford (Calif) University Medical Center were routinely prescribed long-term calcium carbonate antacid therapy to aid in the prevention of peptic ulcer disease and osteoporosis associated with glucocorticoid immunosuppressive therapy. Patients consumed 4 to more than 10 g/d of elemental calcium. Since calcium carbonate also provides the essential ingredients for the development of the milk-alkali syndrome, the laboratory flow sheets of 297 heart and heart-lung transplant recipients were reviewed to examine the incidence of hypercalcemia. ⋯ It is likely that most of these patients had the milk-alkali syndrome. While most patients became eucalcemic by discontinuing calcium carbonate therapy, intravenous hydration and forced diuresis were used to treat severe cases. It is possible that the incidence of the milk-alkali syndrome will increase with the current popularity of prescribing calcium carbonate for the prevention and treatment of osteoporosis.
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Published studies of the blood pressure response to exercise were reviewed to assess the probability of future hypertension in a subject with a "hypertensive" response to exercise. The reviewed data indicate that the sensitivity of a hypertensive response to exercise for future hypertension varied between 16% and 60%, and the specificity between 53% and 95%. ⋯ However, this predictive value is limited, since 38.1% to 89.3% of those with a hypertensive response to exercise did not have hypertension on follow-up, and a normotensive response only marginally reduced the risk of future hypertension. The use of exercise testing as a predictor of hypertension is still in need of experimental development and confirmation.
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Tumors of unknown origin represent a common presentation of malignancy. However, tumors of unknown origin presenting as bone marrow metastases are infrequently reported. The records of 11,820 bone marrow biopsy procedures over a 15-year period at a university hospital and a veteran's hospital were reviewed, disclosing 25 cases of tumor of unknown primary site. ⋯ Anemia, thrombocytopenia, and a leukoerythroblastic blood picture were common hematologic findings. Examination for detection of the primary site was usually unrewarding. The median survival of patients was very short (18 days) and therapy seldom altered survival.
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We studied 211 sets of pulmonary function data to evaluate spirographic findings in patients with restrictive defects, and to determine the significance of the spirographic interpretation of restriction. A combination of clinical and body plethysmographic data was used as the standard for the diagnosis of restriction. ⋯ Ten percent of patients with pure obstructive defects by clinical and plethysmographic criteria showed a restrictive defect on the spirogram. Combined obstructive and restrictive defects were rare; in these cases the spirogram showed a restrictive defect but missed the obstructive component.