Managing Renal Cell Carcinoma Associated Paraneoplastic Syndrome with Nephron-sparing Surgery in a Patient with von Hippel-Lindau.

A patient with germline von Hippel-Lindau (VHL) gene alteration and history of multiple tumors present with classical paraneoplastic syndrome (PNS) associated with renal cell carcinoma (RCC). She underwent open nephron sparing surgery with resolution of symptoms. She remained without recurrence of RCC for the initial 2 years of her follow-up. To the best of our knowledge, this case represents the first in which PNS was specifically resolved using a partial nephrectomy in a patient with VHL. This case report provides initial evidence for the potential role of nephron sparing surgery in the management of paraneoplastic symptoms associated with hereditary RCC

Myocardial metabolic and hemodynamic effects of dobutamine in heart failure complicating coronary artery disease.

Eighteen patients with congestive heart failure (CHF) complicating coronary artery disease (CAD) and seven patients with CHF due to primary cardiomyopathy (CM) were studied during infusions of dobutamine in doses of 2.5-15.0 μg/kg/min. There were statistically significant (p \u3c 0.05) improvements in cardiac index, stroke volume index, left ventricular stroke work index and nuclear ejection fraction in both groups. Significant decreases (p \u3c 0.05) in pulmonary capillary wedge pressure, right atrial pressure, and systemic and pulmonary vascular resistances were also observed in both groups. However, five patients increased an already elevated pulmonary capillary wedge pressure during dobutamine infusion, which was associated with either the development of angina pectoris or with a significant elevation of the mean arterial pressure. In the CAD patients, gated cardiac scans analyzed for segmental wall motion showed improvement in 27% of the abnormally contracting segments during dobutamine infusion. Finally, the effects of dobutamine on myocardial metabolism were assessed with arterial and coronary sinus lactate analysis. Fourteen of the 18 CAD patients (78%) showed no metabolic abnormality during dobutamine infusion; four CAD patients (22%), three of whom developed typical angina pectoris, displayed abnormal lactate metabolism. None of the CM patients developed angina pectoris or displayed abnormal lactate metabolism. Of the seven patients with an adverse hemodynamic or metabolic response, four had recently been withdrawn from propranolol therapy. In conclusion, dobutamine produced favorable effects of hemodynamics, left ventricular ejection fraction, and segmental wall motion abnormalities in most patients with CHF without a deleterious effect on myocardial metabolism

Myocardial metabolic and hemodynamic effects of dobutamine in heart failure complicating coronary artery disease

Eighteen patients with congestive heart failure (CHF) complicating coronary artery disease (CAD) and seven patients with CHF due to primary cardiomyopathy (CM) were studied during infusions of dobutamine in doses of 2.5-15.0 μg/kg/min. There were statistically significant (p \u3c 0.05) improvements in cardiac index, stroke volume index, left ventricular stroke work index and nuclear ejection fraction in both groups. Significant decreases (p \u3c 0.05) in pulmonary capillary wedge pressure, right atrial pressure, and systemic and pulmonary vascular resistances were also observed in both groups. However, five patients increased an already elevated pulmonary capillary wedge pressure during dobutamine infusion, which was associated with either the development of angina pectoris or with a significant elevation of the mean arterial pressure. In the CAD patients, gated cardiac scans analyzed for segmental wall motion showed improvement in 27% of the abnormally contracting segments during dobutamine infusion. Finally, the effects of dobutamine on myocardial metabolism were assessed with arterial and coronary sinus lactate analysis. Fourteen of the 18 CAD patients (78%) showed no metabolic abnormality during dobutamine infusion; four CAD patients (22%), three of whom developed typical angina pectoris, displayed abnormal lactate metabolism. None of the CM patients developed angina pectoris or displayed abnormal lactate metabolism. Of the seven patients with an adverse hemodynamic or metabolic response, four had recently been withdrawn from propranolol therapy. In conclusion, dobutamine produced favorable effects of hemodynamics, left ventricular ejection fraction, and segmental wall motion abnormalities in most patients with CHF without a deleterious effect on myocardial metabolism

Evaluation of technician audiovisual scanning of ambulatory electrocardiograph recordings utilizing the rapid oscillographic printout technique of validation

Summary: The accuracy of technician audiovisual scanning of ambulatory electrocardiographic recordings, coupled with physician review of demonstrative rhythm strips, was validated using the rapid oscillographic printout technique. Seventy‐five patients underwent 24‐h ambulatory electrocardiographic recordings which were routinely evaluated by audiovisual scanning for the highest hourly grades of ventricular ectopic activity (VEA). Printouts of three random hours per 24‐hours were then obtained (one hour per 8‐hour period). The total beat oscillographic printouts, written at 120 × real time, were then graded by at least two authors and compared to the results of audiovisual scanning. Hourly VEA grades were: 0 = no ventricular ectopy; 1 = ≤ 10 unifocals; 2 = \u3e 10 unifocals; 3 = ≤ 10 multifocals; 3A = \u3e 10 multifocals; 4 = couplets; 5 = triplets or salvos. VEA grades were further grouped into high grade (2, 3A, 4 or 5) and low grade (0, 1, or 3) categories. The comparison of rapid oscillographic total beat printout to technician audiovisual scanning coupled with physician review of ambulatory electrocardiographic data produced the following conclusions: (1) The highest hourly VEA grade was exactly identified 65% (146/225) of the time, or was closely approximated (identified within one grade of the highest VEA grade) 80% (181/225) of the time. Excluding errors that were secondary to overlooking rare electrical events, technicians successfully identified 88% (199/225) of hours for the highest VEA grade; (2) patients with high grade and low grade VEA were identified with an accuracy of 91% (51/55) and 95% (19/20), respectively; (3) technician reports which combined each of the three random hours per patient were more predictably accurate when positive for high grade VEA (98% of patients, 50/51) than for low grade VEA (79% of patients, 19/24); p \u3c 0.05); (4) “underreading” errors in audiovisual scanning were almost six times more frequent as those of “overreading” (67 vs. 12 instances, respectively), with a failure to recognize low frequency electrocardiographic events as the most prevalent type of error. This study demonstrates the use of the rapid oscillographic printout technique for the display of ambulatory electrocardiographic data in hard copy compressed form which was successfully used to validate technician performance in the audiovisual scanning of ambulatory ECG recordings. Copyright © 1982 Wiley Periodicals, Inc

Role of aminophylline in refractory heart failure: a comparison to the vasodilator sodium nitroprusside, the old and the new

Aminophylline [(theophylline ethylene diamine (TED)] reportedly improves cardiac hemodynamics by lowering vascular resistances and increasing contractility. TED as used clinically has not been compared to the vasodilator sodium nitroprusside (NP). To assess the relative hemodynamic effects of these two commonly used agents, the following comparison was made. Ten patients with congestive cardiomyopathy in chronic refractory heart failure [New York Heart Association (NYHA) class IV] were studied. All patients demonstrated cardiomegaly by chest x ray and echocardiography (LVd = 6.3 ± 0.7 cm) and markedly abnormal hemodynamics during baseline observations (see Table I). Hemodynamic measurements at baseline were compared after TED infusion (mean blood level = 16±12 m̈g/m/TED) and during intravenous NP. No significant changes in heart rate occurred during either therapeutic intervention; a fall in mean arterial pressure of 10 mmHg (p\u3c0.01) was observed during NP therapy; atrioventricular (AV) block with ventricular fibrillation was successfully treated in one patient after TED. Theophylline ethylene diamine demonstrated no detectable cardiac hemodynamic effects 60–90 min post infusion despite proven blood levels, whereas NP exhibited distinctly beneficial effects in this patient group. Previous studies demonstrating improved hemodynamics occurring with TED have been limited to the time of infusion or within the following 40 min, a time when TED blood levels are maximum and therefore closest to toxicity. The results of this study suggest that TED demonstrates no beneficial hemodynamic effects in refractory heart failure as early as 1 h after infusion despite blood levels in the therapeutic range. Copyright © 1980 Wiley Periodicals, Inc

Pulmonary effects of acebutolol, a \u27cardioselective\u27 beta adrenergic blocking agent

The effect of chronic oral therapy with acebutolol, a cardioselective beta adrenergic blocking agent, was evaluated on resting pulmonary functions in a group of patients who were free of overt obstructive airways disease and who had chronic stable angina pectoris. The study design involved a 20-week, placebo-controlled, double-blind, randomized cross-over trial, using acebutolol, an agent with partial agonist activity that has been shown to be effective in the treatment of hypertension, cardiac arrhythmias, and angina pectoris. Utilizing spirometry, flow volume loops, and arterial blood gas analyses, this study demonstrated that acebutolol had no significant deleterious effect on resting pulmonary function when used in clinically effective dosages