Clinical characteristics and diagnosis of stenocardia in persons with normal coronary vessels

To date, the clinical pattern and electrocardiographic diagnosis of only one variant of coronary heart disease (CHD) with unchanged coronarogram, Prinzmetal's angina, have been worked out, while the diagnosis of other variants remains undeveloped. Clinical symptoms and possibilities of CHD diagnosis in the presence of intact coronary arteries have been evaluated in 67 coronary patients, the coronarograms being normal in 46 of those. The diagnosis of CHD was verified by means of various instrumental methods, including electrocardiographic tests and myocardial metabolic studies in conditions of frequent atrial stimulations. The results were computerized, using a specifically designed programme. Sets of signs identifying coronary patients with intact coronary arteries at questioning and noninvasive investigation are presented.     

Clinical heterogeneity in chronic myeloid leukaemia reflecting biological diversity in normal persons

The molecular basis of chronic myeloid leukaemia (CML) is well defined and highly consistent, yet prognosis varies considerably. This could reflect the biological diversity occurring in normal populations. We used a colony replating assay to measure the proliferative capacity of progenitor cells from 211 CML patients and 86 normal persons. Results were expressed as the frequency distributions of the proliferation index (PI) for individual cases. Normal PI values varied among individuals but were reproducible in individuals. The PIs for CML patients were moderately but significantly greater (P = 0.004) than normal values, consistent with increased progenitor cell proliferation in CML. Exposure of CML progenitor cells to the Abl-kinase inhibitor imatinib shifted their PI towards the normal range, implicating p210BCR-ABL. as a cause of the increased PI. The PIs of CML patients were higher than those of their human leucocyte antigen (HLA)-matched siblings PI (P = 0.003) and patient PI increased exponentially with sibling PI (r = 0.77; P = 0.001), but not with the PI values of HLA-matched unrelated individuals (P = 0.66). Finally, patients with high-risk prognostic scores (according to the Sokal or Hasford systems) had a significantly higher PI than those with low risk scores (P = 0.01 and 0.03 respectively). We conclude that heterogeneity in the CML patient population is analogous to the constitutional diversity in normal subjects.     

The insulin receptor in normal and obese persons.

Using [125I]insulin at 172 pmol/1 (1 ng/ml) the binding of insulin to mononuclear leucocytes isolated from peripheral blood was studied. Our present study comprised 21 healthy subjects (22-33 years old, 90-110% of ideal weight) and a comparable group of 22 obese subjects (20-37 years old, minimum 150% of ideal weight). A significant difference in insulin binding was found between the two groups, the mean specific insulin binding fraction in normals being 1.92 +/- 0.58 (s) X 10(-2) and that for the obese 1.19 +/- 0.41 (s) X 10(-2) (P less than 0.01). No correlation was found between body weight and the number of insulin receptors in the obese subjects. However, the number of insulin receptors was negatively correlated to fat cell size (P less than 0.05). Insulin receptors in subjects were also negatively correlated to fasting plasma insulin (P less than 0.05). Insulin receptors were studied in 11 obese subjects before and after 10 days of fasting. A significant increase in the number of insulin receptors was observed with a simultaneous decrease in plasma insulin to normal values. The results indicate that obesity complicated by hyperinsulinism is associated with a decrease in the number of insulin receptors compared with the normal. This finding may in part explain the decreased insulin sensitivity of the hyperinsulinaemic obese.     

Age and sex-dependent alterations of serum amylase and isoamylase levels in normal human adults

Total amylase and salivary-and pancreatic-type isoamylase levels were assayed in sera from 606 apparently healthy adults of different sex and age groups. There were significant differences in both total amylase and isoamylase levels, depending on age and sex, one of the characteristics being that levels of these three enzymes were significantly higher in the elderly group in both men and women than in other age groups. Another feature was that all of these enzyme levels were significantly greater in women in the third and fourth decade than in men. Age and sex differences should be taken into consideration in the evaluation of mild hyperamylasemia.     

Serum pancreatic isoamylase activity in pancreatic disease.

The diagnostic value of serum amylase determination for pancreatic disease has been questioned due to its lack of specificity. Several methods have been developed to separate the tissue-unspecific salivary fractions from the tissue-specific pancreatic fractions. Agarose or cellulose acetate gel electrophoresis are most suitable for clinical practice. The isoamylase patterns were studied by agarose electrophoresis in 55 patients with known pancreatic diseases (acute pancreatitis, pancreatic pseudocysts, exocrine pancreatic insufficiency and pancreatic carcinoma). Increased P-type isoamylase seems to be more sensitive than total amylase in diagnosing acute pancreatitis, while identification of the minor isoamylase P3 is more specific and could have a prognostic value. Detection of low P-type isoamylase levels is an easy method to diagnose exocrine pancreatic insufficiency. Furthermore, a group of patients with pancreatic disease (Pa), was compared with a group of patients with biliary disease without clinical evidence of pancreatic involvement (Bi), and patients with abdominal pain, without evidence of biliary or pancreatic disease (Ab). More than half of the Bi patients presented with abnormal P isoenzyme patterns, whereas 72% of the Ab patients had a normal pattern. Only P3 could distinguish between the Bi and Ab group. This might point to pancreatic involvement in patients presenting with biliary disease, only detected by isoamylase analysis.     

Fecal isoamylase activity in patients with pancreatic diseases.

Fecal isoamylase activity was studied in 93 consecutive patients (26 in the recovery stage of acute pancreatitis, 24 with chronic pancreatitis, 13 with pancreatic cancer, and 30 with other gastrointestinal diseases) and compared with fecal chymotrypsin activity and the results of the secretin test. Seventy-six healthy subjects were studied as controls. Both pancreatic (p)-type and salivary (s)-type isoamylase activities in stool were determined by inhibitor assay as well as cellulose acetate electrophoresis. The mean fecal amylase activity in healthy subjects was 757 +/- 88 IU/g (p-type isoamylase: 77 +/- 2%, s-type isoamylase: 23 +/- 2%). There was a good correlation between fecal p-type isoamylase and chymotrypsin activities (r = 0.625, p less than 0.001). Fecal p-type isoamylase activity in patients with chronic pancreatitis and pancreatic cancer was significantly lower than in healthy subjects (p less than 0.001). Patients with moderate and severe exocrine pancreatic insufficiency as determined by the secretin test had significantly lower fecal p-type isoamylase activity. Daily fat intake did not affect fecal amylase or isoamylase activities. Fecal s-type isoamylase activity in patients with hypoacidity was significantly higher than in patients with hyperacidity, but no difference in fecal p-type isoamylase activity was observed. It is concluded that analysis of fecal isoamylase activity is useful in the assessment of pancreatic function.     

Clinical challenges in the care of frail older persons

The clinical challenges of meeting the needs of frail older persons are essentially those encompassed by chronic disease multiplied by the special problems presented by aging, namely the presentation and management of disease and the special syndromes associated with geriatrics. The need to develop an approach to the care of frail older persons reflects a more general need to address system reform for chronic disease. The steps include new roles for patients and their families, the use of information technology to monitor changes in patients' status more continuously and to intervene in a more timely way, and a re-evaluation of the use of personnel at all levels. At present, we know more about how to deliver effective chronic care than we practice. The barriers to implementation include both a general reluctance to change and negative financial incentives to implement what has been shown to be effective.     

Clinical evaluation of the obese patient.

An appropriate evaluation is the first step in developing a treatment plan for the overweight individual. The medical history should evaluate aetiological factors that may have played a role in the development of obesity. The physical examination and laboratory tests should extend this evaluation to risk factors associated with obesity. The natural history of the development of obesity then provides a guide to selecting appropriate treatment algorithms.