Medicine Newbie: September 2009

Sunday, 20 September 2009

Stroke & Articulation Error

Multimedia Speech Pathology

Pelat or telor (Malay/Bahasa Malaysia, pelat; Kelantan, telor, kecek telor) is articulation error. It is not due to stroke or brain injury. It can be congenital (present at birth) or acquired (after birth). It can arise from articulators mechanism, which involve muscles of the tongue, palates (soft & hard palates)(Malay lelangit, langit-langit), labia (lips; Malay bibir), jaw and aevolar ridge (Malay hujung langit-langit berhampiran gigi).

Dysarthria is a speech problem. Possible causes are stroke or brain injury (fall affecting the head, shot in the head, concussion, hit on the head by foregin object, etc). It involves 5 components - respiration/breathing, resonance, phonation, articulation and ______.

Aphasia is resultant from stroke or brain injury. It is an acquired speech & language disorder.

Speech apraxia is the inability to reproduce sounds after hearing them. It involves voluntary (volitional) and involuntary (involitional) conditions. It is a processing problem.

More at www.mmsp.com.au

Brain Anatomy

Multimedia images

3D brain sections in full colour and multimedia.

Tuesday, 8 September 2009

Diastolic heart failure and pulmonary hypertension

Heart and lung involvement

Figure 1 – Severe left ventricular hypertrophy and grade 1 diastolic heart failure are revealed by echocardiography and Doppler ultrasonography. The apical 4-chamber view shows a thickened left ventricular wall and enlarged left atrium (A). Doppler evaluation shows impaired early diastolic relaxation (E wave) and vigorous atrial contraction (A wave) resulting in an E/A ratio of less than 0.75, which signifies early reduced left ventricular compliance (B). A normal E/A ratio is greater than 1.5, since most of the diastolic filling occurs early in a compliant left ventricle with the atrial component contributing a smaller volume at a lower velocity. (LV, left ventricle; LA, left atrium.)

Heart failure with normal ejection fraction (HFNEF) contributes to the largest number of cases of pulmonary hypertension (PH) in the elderly. Studies have shown that isolated HFNEF is present in 44% to 60% of patients with heart failure.^20,21 In contrast to systolic dysfunction, HFNEF results from impaired myocardial relaxation resulting in decreased compliance and impairment of diastolic ventricular filling; the problem is not with ventricular contraction but rather with diastolic relaxation.
The most common causes of HFNEF are coronary artery disease, hypertension, aging, obesity, and aortic stenosis. The diagnosis is based on the presence of heart failure symptoms in the absence of depressed ejection fraction. An echocardiogram with Doppler studies can be useful in diagnosing diastolic dysfunction. The E/A ratio, in which E denotes the early peak mitral diastolic inflow velocity and A denotes the late diastolic peak mitral inflow velocity, can be useful.
Under normal conditions, E is greater than A and the E/A ratio is approximately 1.5. In early diastolic dysfunction, relaxation is impaired and there is vigorous atrial contraction, resulting in an E/A ratio of less than 0.75 (Figure 1). As the disease progresses, left ventricular (LV) compliance is reduced further, which increases early LV filling despite impaired relaxation, resulting in pseudonormalization of the E/A ratio to 1.5. In severe diastolic dysfunction, the E/A ratio is greater than 2 as a result of the LV filling occurring primarily in early diastole.²²Source: Pulmonary hypertension in the elderly, part 2: Treatmenthttp://jrd.consultantlive.com/display/article/1145425/1405017?pageNumber=6

Left ventricular hypertrophy and diastolic dysfunction

Kidney patients and their heart problems

Patients with chronic renal failure (CRF) on maintenance hemodialysis (HD) experience a series of metabolic and hemodynamic abnormalities that predispose to anatomic and functional change in myocardial performance¹. Thus, left ventricular (LV) hypertrophy, a geometric change independently predictive of mortality^2,3, is usually accompanied by diastolic dysfunction. Left ventricular systolic dysfunction seems to be less frequent^4,5, although it also adds prognostic value⁶.

REFERENCES

1. Alpert MA. Cardiac performance and morphology in end-stage renal disease. Am J Med Sci. 2003; 325: 168-78. [ Links ]

2. Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE. The prognostic importance of left ventricular geometry in uremic cardiomyopathy. J Am Soc Nephrol. 1995; 5: 2024-31. [ Links ]

3. London GM. Cardiovascular disease in chronic renal failure: pathophysiologic aspects. Semin Dial. 2003; 16: 85-94. [ Links ]

4. Sarnak MJ. Cardiovascular complications in chronic kidney disease. Am J Kidney Dis. 2003; 41: 11-7. [ Links ]

5. London GM. Left ventricular alterations and end-stage renal disease. Nephrol Dial Transplant. 2002; 17 Suppl 1: 29-36. [ Links ]

6. Sarnak MJ, Levey AS, Schoolwerth AC, et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation 2003; 108: 2154-69. [ Links ]

Grade 2 diastolic dysfunction

What is "grade 2 diastolic dysfunction"? Serious or not?

There are four basic Echocardiographic patterns of diastolic heart failure, graded I to IV.

Grade I diastolic dysfunction is the mildest form and is called an abnormal relaxation pattern. On the mitral inflow Doppler echocardiogram, there is reversal of the normal E/A ratio. This pattern may develop normally with age in some patients and many grade I patients will not have any clinical signs or symptoms of heart failure.

Grade II diastolic dysfunction is called pseudonormal filling dynamics. This is considered moderate diastolic dysfunction and is associated with elevated left atrial filling pressures. These patients more commonly have symptoms of heart failure and many have left atrial enlargement due to the elevated pressures in the left heart.

Grade III and IV diastolic dysfunction are called restrictive filling dynamics. These are both severe forms of diastolic dysfunction and patients tend to have advanced heart failure symptoms.

Class III diastolic dysfunction patients will demonstrate reversal of their diastolic abnormalities on echocardiogram when they perform the Valsalva maneuver and are called reversible restrictive diastolic dysfunction.

Class IV diastolic dysfunction patients will not demonstrate reversibility of their echocardiogram abnormalities and are therefore called fixed restrictive diastolic dysfunction. The presence of either class III and IV diastolic dysfunction is associated with a significantly worse prognosis. These patients will have left atrial enlargement and many will have a reduced left ventricular ejection fraction indicating a combination of systolic and diastolic dysfunction. - Wikipedia