Asymptomatic Adult Patients Research Articles

Risk stratification in the asymptomatic child with Wolff–Parkinson–White syndrome

As the safety and efficacy of invasive electrophysiologic studies and ablation therapy in pediatrics improves, there has been a greater interest in developing adequate risk stratification criteria for the asymptomatic pediatric patient with Wolff-Parkinson-White syndrome. This review will discuss the recent literature regarding this debate. Recent retrospective and prospective studies of Wolff-Parkinson-White syndrome in asymptomatic pediatric patients have shown that the well established adult criteria for risk stratification may not be applicable in children. Both symptomatic and asymptomatic children had similar accessory pathway effective refractory periods and supraventricular tachycardia inducibility in recent invasive electrophysiologic studies. The first attempt at prospective evaluation of the use of ablation therapy in asymptomatic adult and pediatric patients with the condition has sparked a debate as to the definition of a high-risk patient and the utility of ablation in the asymptomatic patient. It is still controversial whether the established criteria for risk stratification in adults can be confidently applied to the pediatric patient. The majority of pediatric electrophysiologists use invasive electrophysiologic studies for risk stratification and selection of appropriate therapy. This clinical practice reflects the increasing prevalence and safety of electrophysiologic study and ablation. Further studies to better define indications for study and ablation are still necessary, however, to define accurate criteria for risk stratification in this difficult pediatric problem.

Quality of life in asymptomatic adult celiac patients a case control study

Quality of life in asymptomatic adult celiac patients a case control study

Mycobacterium abscessus Pulmonary Infection Presenting as a Solitary Pulmonary Nodule

Nontuberculous mycobacterial pulmonary infection is a rare cause of a solitary pulmonary nodule. All previously reported cases were caused by Mycobacterium avium complex, and a solitary pulmonary nodule caused by other NTM species has been very rarely reported. We describe the first case of Mycobacterium abscessus infection presenting as a solitary pulmonary nodule in a 51-year-old asymptomatic adult patient.

Incidence and clinical significance of spontaneous intrahepatic portosystemic venous shunts detected by sonography in adults without potential cause

B-mode and color Doppler sonography were used to assess the incidence and clinical significance of spontaneous intrahepatic portosystemic venous shunt in adults without detectable cause. A total of 25,579 adults without potential cause of intrahepatic portosystemic venous shunt were screened using B-mode sonography. Suspicion of shunt was confirmed by color Doppler sonography. Patients with shunt were followed up with sonography at 6- to 12-month intervals and received dietary education to prevent the ingestion of extra-large amounts of protein. During each sonography session, the patients were asked to report any experience of consciousness disturbance. Six patients (0.0235%) showed evidence of shunt on color Doppler sonography. Direct communication between a right portal branch and the inferior vena cava was found in 3 patients; a small aneurysm connecting a peripheral portal branch to the hepatic vein was found in the remaining 3 patients. Five patients were followed up (range, 12-60 months) and showed no change in the size of the shunt. None of the patients with shunt reported an experience of consciousness disturbance. The incidence of spontaneous intrahepatic portosystemic venous shunt is extremely low in asymptomatic adult patients. Follow-up and dietary control seen to be suitable for their management.

Tissue Doppler Imaging and Brain Natriuretic Peptide Levels in Adults with Repaired Tetralogy of Fallot

Accurate estimation of right ventricular (RV) function in patients with repaired tetralogy of Fallot (RTOF) is difficult, partly due to the presence of tricuspid regurgitation and pulmonary regurgitation and/or stenosis. The aim of the present study was to evaluate RV systolic and diastolic function of adult asymptomatic patients with RTOF by means of tissue Doppler imaging (TDI) and brain natriuretic peptide (BNP) values. 25 adult patients with RTOF and 25 healthy controls were studied. The following echocardiographic measurements were obtained: RV diameter/left ventricular (LV) diameter (RVD/LVD) and systolic (Sa) and diastolic (Ea, Aa) velocities at the RV free wall tricuspid annulus site. Serum BNP levels were measured as well. Patients with RTOF demonstrated reduced TDI velocities: Sa, 8.16 +/- 1.15 versus 16.43 +/- 1.15 cm/sec (P < .001); Ea, 10.00 +/- 2.18 versus 18.99 +/- 1.00 cm/sec (P < .001); Aa, 5.64 +/- 1.77 vs. 13.69 +/- 0.86 cm/sec (P < .001). Patients with RTOF also had higher BNP levels than controls (85.0 +/- 87.0 vs 5.36 +/- 1.0 pg/mL; P < .001). The increased BNP levels in RTOF patients correlated with the RVD/LVD ratio (r = .521; P < .01). Our results indicate that although our cohort of patients was asymptomatic, using TDI and BNP allowed us to easily discriminate them from the healthy controls. The ability of TDI to assess ventricular function even in the presence of valvular lesions, as in RTOF patients, makes it a valuable tool in the investigation and follow-up of these patients.

Asymptomatic Adult Patients With Aortic Stenosis: Should They Ever Have Aortic Valve Replacement?

Presently, conventional wisdom is that an asymptomatic patient, even with severe aortic stenosis (AS), can be followed medically. The basis for this recommendation is that sudden death as the first "symptom" in an asymptomatic patient is rare. Unfortunately, symptoms are subjective and can be ignored or explained away by both patient and physician, and once symptoms are recognized, sudden death accounts for at least one third of the deaths from AS in unoperated patients. There is evidence that once AS becomes severe, ischemia and fibrosis occur rapidly, setting up the possibility of heart failure and sudden death even after successful valve replacement. Aortic valve replacement should be performed before extensive fibrosis occurs. Multiple studies have shown that in severe AS, symptoms will occur rapidly when there is heavy valve calcification, an aortic valve area <0.8 cm, an annual rate of progression of aortic valve velocity of >/=0.3 m/sec, or a positive exercise stress test. These findings are excellent evidence that asymptomatic patients with severe AS and any of the above findings should be considered for aortic valve replacement.

Asymptomatic Carriers of Plasmodium spp. as Infection Source for Malaria Vector Mosquitoes in the Brazilian Amazon

We have described the existence of asymptomatic carriers of Plasmodium vivax and Plasmodium falciparum infections in native Amazon populations. Most of them had low parasitemias, detected only by polymerase chain reaction (PCR). Because they remain symptomless and untreated, we wanted to determine whether they could infect Anopheles darlingi Root, the main Brazilian vector, and act as disease reservoirs. Fifteen adult asymptomatic patients (PCR positive only) were selected, and experimental infections of mosquitoes were performed by direct feeding and by a membrane-feeding system. Seventeen adult symptomatic patients with high parasitemias were used as controls. We found an infection rate in An. darlingi of 1.2% for the asymptomatic carriers and 22% for the symptomatic carriers. Although the asymptomatic group infected mosquitoes at a much lower rate, these patients remain infective longer than treated, symptomatic patients. Also, the prevalence of asymptomatic infections is 4 to 5 times higher than symptomatic infections among natives. These results have implications for the malaria control program in Brazil, which focuses essentially on the treatment of symptomatic patients.

Asymptomatic Carriers of &lt;I&gt;Plasmodium&lt;/I&gt; spp. as Infection Source for Malaria Vector Mosquitoes in the Brazilian Amazon

We have described the existence of asymptomatic carriers of Plasmodium vivax and Plasmodium falciparum infections in native Amazon populations. Most of them had low parasitemias, detected only by polymerase chain reaction (PCR). Because they remain symptomless and untreated, we wanted to determine whether they could infect Anopheles darlingi Root, the main Brazilian vector, and act as disease reservoirs. Fifteen adult asymptomatic patients (PCR positive only) were selected, and experimental infections of mosquitoes were performed by direct feeding and by a membrane-feeding system. Seventeen adult symptomatic patients with high parasitemias were used as controls. We found an infection rate in An. darlingi of 1.2% for the asymptomatic carriers and 22% for the symptomatic carriers. Although the asymptomatic group infected mosquitoes at a much lower rate, these patients remain infective longer than treated, symptomatic patients. Also, the prevalence of asymptomatic infections is 4 to 5 times higher than symptomatic infections among natives. These results have implications for the malaria control program in Brazil, which focuses essentially on the treatment of symptomatic patients.

Slow Genetic Divergence of Helicobacter pylori Strains during Long-Term Colonization

The genetic variability of Helicobacter pylori is known to be high compared to that of many other bacterial species. H. pylori is adapted to the human stomach, where it persists for decades, and adaptation to each host results in every individual harboring a distinctive bacterial population. Although clonal variants may exist within such a population, all isolates are generally genetically related and thus derived from a common ancestor. We sought to determine the rate of genetic change of H. pylori over 9 years in two asymptomatic adult patients. Arbitrary primed PCR confirmed the relatedness of individual subclones within a patient. Furthermore, sequencing of 10 loci ( approximately 6,000 bp) in three subclones per time and patient revealed only two base pair changes among the subclones from patient I. All sequences were identical among the patient II subclones. However, PCR amplification of the highly divergent gene amiA revealed great variation in the size of the gene between the subclones within each patient. Thus, both patients harbored a single strain with clonal variants at both times. We also studied genetic changes in culture- and mouse-passaged strains, and under both conditions no genetic divergence was found. These results suggest that previous estimates of the rate of genetic change in H. pylori within an individual might be overestimates.

Low-Dose Gluten Challenge in Celiac Sprue: Malabsorptive and Antibody Responses

Undiagnosed patients with symptoms of celiac sprue often present to physicians after establishing dietary gluten exclusion. Although they must resume a gluten-containing diet for evaluation, there are no guidelines regarding duration of the gluten challenge, gluten dose, or monitoring parameters. We investigated the effects of a short-term gluten challenge in asymptomatic treated adult celiac patients on intestinal absorption and celiac antibody tests. Eight adult asymptomatic celiac patients consumed either 5 or 10 g of partially hydrolyzed gluten per day in an orange juice mixture for 21 days while maintaining their usual gluten-free diet. A symptom questionnaire, serum antibodies (antigliadin immunoglobulin [Ig]A and antitransglutaminase IgA and IgG), D-xylose urine excretion test, and 72-hour quantitative fecal fat test were monitored. Two patients (25%) had at least 1 abnormal celiac antibody test at baseline. There was no increase in antibodies during gluten exposure compared with baseline for any of the patients (P > .05). At baseline, 1 patient had abnormal urine xylose excretion, and 3 patients had abnormal fecal fat values. At day 15 of gluten challenge, all patients had reduced xylose absorption compared with baseline (P = .0019), and 5 of 8 participants (63%) reduced their xylose excretion to the abnormal range. Seven of 8 patients (88%) had increased fecal fat excretion at day 15 (P = .026), and 6 of these (75%) had steatorrhea by day 15. Short-term gluten challenge in asymptomatic adult celiac patients produces carbohydrate and fat malabsorption but does not increase transglutaminase and antigliadin antibody titers.

Adult Complex Spinal Dysraphism With Situs Inversus Totalis: A Rare Association and Review

First published report of an adult complex spinal dysraphism with situs inversus. To describe a previously asymptomatic adult patient of multiple vertebral anomalies with cervical split cord malformation type II, tethering of the spinal cord (cervical and lumbar), and intraspinal arachnoid cyst along with dextrocardia and situs inversus. Only 5 cases (fetus, 1; neonates, 3; child, 1) of spinal dysraphism with dextrocardia or situs inversus have been reported. All these cases have had associated multiorgan developmental anomalies usually incompatible with survival and requiring multidisciplinary care. The case has been described and relevant literature reviewed. The patient was operated for cervical and lumbar levels in the same sitting. A C4-C5 laminectomy was performed, 2 hemicords enclosed in the same dural sac were visualized, dorsal paramedian nerve roots and the tethering arachnoid bands were cut, and the arachnoid cyst wall was partially excised. This was followed by L4-L5 laminectomy and detethering by sectioning of the thickened filum terminale. The patient showed significant neurologic improvement after surgery. The present case is a rare instance in which there has been an association of adult onset occult spinal dysraphism along with situs inversus totalis. Successful management requires appropriate understanding of embryology, anatomy, and imaging and has implications in neurosurgical and perioperative anesthetic care.

Hamartochondrome pulmonaire : une cause rare de nodule pulmonaire solitaire en pédiatrie

Pulmonary hamartochondroma: a rare cause of solitary pulmonary nodule in children J Radiol 2005;86:79-82. Solitary pulmonary nodules are rare in children. We report an eleven year-old girl evaluated for recurrent respiratory symptoms diagnosed with an intraparenchymal pulmonary hamartochondroma. Spiral computed tomography showed a pulmonary nodute in the middle lobe, 17 mm in diameter, without any specifie features. In asymptomatic adult patients, guidelines for the management of solitary pulmonary nodules have been described. The management of solitary pulmonary nodules in pediatrie patients is discussed.

Brain Perfusion Abnormalities in Neurologically Asymptomatic Adult Patients with Sickle Cell Disease. A Voxel-Based Analysis of Brain Spect Imaging.

Sickle cell diseases (SCD) are characterized by the presence of hemoglobin S, hemolytic anemia and vascular occlusion. Silent infarcts in SCD patients is strongly associated with an increased stroke risk and progressive cognitive decline. In this study we used 99mTc-ECD single photon emission computerized tomography (SPECT) in order to detect early abnormalities of brain perfusion in neurologically asymptomatic adult SCD patients. We recruited 42 SCD (27 females and 15 males, mean age of 33.4±10.55, range 17–60 years) from the Hematology and Hemotherapy Center of the University of Campinas.The SCD types were distributed as follows: 33 HbSS (14 males and 19 females), 6 HbSC (1 male and 5 females) and 3 HbSBeta (3 females). Mean steady state hemoglobin level measured in the period of up to 2 weeks before or after imaging acquisition was 8.5g/dl (±1.73; 5.2–13.5) and mean hematocrit was 25.1% (±4.85; 15.6–38.5). The group of patients with SCD was compared to a group of control healthy subjects (29 females and 20 males with mean age 31 years ±8; 25–49) recruited within the local community, who were submitted to the same imaging protocol used in the patients.The study was approved by the National Ethical Committee Board and informed-write consent was obtained from all patients. The inclusion criteria for this study was to be at least 17 years old, have a precise clinical and laboratory diagnosis of any SCD, do not have stroke previously and be on regular follow-up in the clinic. All of them were submitted to a standard protocol of brain SPECT image acquisition. Reconstructed transaxial datasets were converted into ANALYZE format and corrected for the orthogonal plane of acquisition using MRIcro software. Voxel-based analysis was performed using SPM2 (Wellcome Department of Cognitive Neurology). Images were spatially normalized to standard anatomical template defined in the atlas of Talairach and Tournoux. The normalized smoothed images underwent group comparison of regional tracer uptake using paired t-test. Contrasts were defined in order to estimate the probability of each voxel to have an increased or decreased tracer uptake in images from patients with SCD compared to images from the normal control group. Reduced tracer uptake was observed in many areas of the brain when compared to normal controls. These areas corresponded predominantly to watershed regions and other brain areas supplied by micro vasculature. We observed a reduced tracer uptake in the central basal forebrain, which includes the basal ganglia and thalami, the anterior frontal region and the watershed region of the temporo-parietal-occipital transition. These regions are to be considered the most significant hypoperfused areas (false discovery rate correction of p<0.05).The findings of our study demonstrate that neurologically asymptomatic SCD patients exhibit a pattern of reduced 99mTc-ECD tracer uptake demonstrated by SPECT. Early diagnosis of such cerebral vasculopathy has prognostic implications and can be determinant in considering therapeutic alternatives to avoid increasing in brain lesion load and progressive disability.

Left anterior descending coronary artery–left ventricular fistula presenting as unstable angina and syncope

Coronary artery fistulae are rare direct communications between a coronary artery and a cardiac chamber, the coronary sinus, the superior vena cava, or the pulmonary artery [1,2]. They may be congenital, or acquired, associated with various disorders, iatrogenic, traumatic, or spontaneous [1–3]. In most cases patients are asymptomatic and the fistulae are discovered during cardiac catheterization for congenital heart anomalies or coronary artery disease [1]. Rarely, they are the cause of heart failure, spontaneous intrapericardial rupture and tamponade, or myocardial ischemia attributed to a coronary “steal” phenomenon [2,4]. The management of coronary artery fistulae depends on associated symptoms, the magnitude of the left-to-right shunt, and the presence versus absence of other cardiac abnormalities [1,4,5]. In asymptomatic adult patients, the management remains controversial [1]. Symptomatic patients can be treated by transcatheter [2,5] or surgical techniques [1,2,4], while in some cases the fistula closes spontaneously [4,6].

Prevalence of “silent” pulmonary emboli in adults after the Fontan operation

ObjectivesThe study was done to determine the prevalence of pulmonary emboli (PE) in asymptomatic adult Fontan patients and to identify the risk factors associated with PE. BackgroundRight atrial thrombi and systemic thromboembolic complications have been reported after the Fontan procedure. However, the frequency of silent PE in this patient population is not known. MethodsAll consecutive adult Fontan patients attending the adult congenital clinic over a six-month period underwent ventilation-perfusion (VQ) scanning and blood testing for thrombophilia tendency. If the VQ scan showed an intermediate or high probability for PE, a computerized tomography (CT) pulmonary angiogram was performed to confirm the presence of PE. ResultsThirty patients (mean age 26 ± 7 years, 57% men) were included in this study. Five (17%) adult Fontan patients had an intermediate or high probability for PE on VQ scan, all of which were confirmed on CT pulmonary angiography. No patient had a thrombophilia tendency. Pulmonary emboli were not present in any patients (30%) taking warfarin. Late age at time of Fontan operation (19 ± 6 years vs. 11 ± 6 years, p = 0.012) and type of Fontan anatomy (p = 0.001) were associated with increased risk of silent PE. ConclusionsSeventeen percent of adult patients with Fontan procedure have clinically silent PE. The long-term hemodynamic implications of this with respect to Fontan attrition over time are unknown. Large randomized prospective studies looking at anticoagulation therapy in all Fontan patients are urgently needed.

Comparable systemic ventricular function in healthy adults and patients with unoperated congenitally corrected transposition using MRI dobutamine stress testing

Background. Failure of the systemic right ventricle (RV) often complicates adult survival in unoperated or physiologically repaired congenitally corrected transposition of the great arteries (CCTGA). Healthy controls schematically represent an optimal outcome of anatomic repair, which is increasingly performed to treat CCTGA. Magnetic resonance imaging dobutamine stress testing measures cardiac reserve, and sets to compare the left ventricle of controls with the systemic RV of unoperated and physiologically repaired patients with CCTGA. Methods. Baseline and stress magnetic resonance imaging (maximum dobutamine dose, 15 μg/kg/min) assessed systemic RV function in 13 minimally or asymptomatic adult patients with CCTGA (unoperated, n = 7; physiologically repaired, n = 6). The left ventricles of 11 healthy age-matched adults served as controls. Results. Baseline and stress end-diastolic volumes were similar between the systemic RV of unoperated patients and the left ventricle of controls, as well as base line end-systolic volumes. Stress ejection fraction was lower in unoperated and physiologically repaired patients (70 ± 6% and 60 ± 5%, respectively, vs healthy controls (84 ± 8%). However, comparable with healthy controls, both subsets of CCTGA patients responded appropriately to dobutamine stress, as illustrated by similar RV stroke volume, heart rate, mean blood pressure, and cardiac index. Conclusions. Compared with the left ventricles of healthy controls, both patient groups had larger systemic RV volumes, diminished ejection fraction, but an appropriate response to dobutamine stress. Values of unoperated patients are closer to normal than physiologically repaired patients. Magnetic resonance imaging dobutamine may help to define the subgroups of CCTGA patients with favorable anatomy, whereby asymptomatic adult survival could be anticipated without the need for an operation.

Nutrition and physical activity counseling practices of family practice residents.

Nutritional behaviors and physical activity can influence risk for the development and prognosis of cancer. This study reports findings of a literature review and a survey of nutrition and physical activity counseling practices of family practice (FP) residents. 110 FP residents (response rate = 93.2%) from four clinics that received funding from the Texas Department of Health completed the survey. Hierarchical linear regression models were used to identify determinants of nutrition and physical activity counseling practices. About a fifth of the residents reported that they usually or always asked their patients about nutrition and physical activity. In general, residents were most likely to address these issues with asymptomatic obese adult patients. Perceived effectiveness was a significant predictor of both assessment and counseling, except for nutrition counseling for asymptomatic patients. Attitude toward behavioral counseling predicted assessment, but not counseling. Use of resources predicted counseling on both topics with all patients. FP residents assess and counsel about nutrition and physical activity at suboptimal rates. There is a need to convince residents of the value of such assessment and counseling and to increase their belief that patients will follow through on their recommendations.

Utility of transesophageal echocardiography for the characterization of cardiovascular anomalies associated with Turner's syndrome

This case illustrates the complementary value of transesophageal echocardiography to routine transthoracic echocardiography in an asymptomatic adult patient with Turner's syndrome. The combined findings of bicuspid aortic valve, severe aortic dilation, coarctation of the aorta, and type A aortic dissection were clearly delineated by transesophageal echocardiography.

An assessment of the role of liver biopsies in asymptomatic patients with chronic liver test abnormalities.

The role of liver biopsy in the management of patients with nonspecific chronic liver enzyme abnormalities is not well established. The aim of this study is to determine whether liver histology changes the clinical impression formed before liver biopsy and the preliminary management plan. Consenting asymptomatic adult patients with persistent (> or = 6 months) liver test abnormalities were enrolled. Patients with a strong suspicion for a specific liver disease were excluded. A presumptive diagnosis and a preliminary management plan were documented before a liver biopsy. After the liver biopsy, the patients were reassessed to determine the effect of the biopsy on the diagnosis and management plan. A total of 36 patients were enrolled: 15 men and 21 women, with a median age of 51 yr. The prebiopsy diagnoses were nonalcoholic steatohepatitis (24), autoimmune hepatitis (3), primary biliary cirrhosis (2), primary sclerosing cholangitis (2), and miscellaneous (5 patients). The liver biopsy changed the diagnosis in 14% of cases. Lifestyle recommendations were not significantly altered by the biopsy. The liver biopsy affected the frequency of liver test monitoring in 13 patients (36%). Treatment recommendations were affected in 12 cases, 10 of whom were offered investigational therapy. Although a liver biopsy may help to definitively establish the final diagnosis in patients, the results alter the presumptive prebiopsy diagnosis infrequently, and no proven therapy exists for the vast majority of these patients. Therefore, the risks and benefits of a liver biopsy should be carefully weighed, especially in settings in which investigational therapies are unavailable.

An assessment of the role of liver biopsies in asymptomatic patients with chronic liver test abnormalities

OBJECTIVE: The role of liver biopsy in the management of patients with nonspecific chronic liver enzyme abnormalities is not well established. The aim of this study is to determine whether liver histology changes the clinical impression formed before liver biopsy and the preliminary management plan. METHODS: Consenting asymptomatic adult patients with persistent (≥6 months) liver test abnormalities were enrolled. Patients with a strong suspicion for a specific liver disease were excluded. A presumptive diagnosis and a preliminary management plan were documented before a liver biopsy. After the liver biopsy, the patients were reassessed to determine the effect of the biopsy on the diagnosis and management plan. RESULTS: A total of 36 patients were enrolled: 15 men and 21 women, with a median age of 51 yr. The prebiopsy diagnoses were nonalcoholic steatohepatitis (24), autoimmune hepatitis (3), primary biliary cirrhosis (2), primary sclerosing cholangitis (2), and miscellaneous (5 patients). The liver biopsy changed the diagnosis in 14% of cases. Lifestyle recommendations were not significantly altered by the biopsy. The liver biopsy affected the frequency of liver test monitoring in 13 patients (36%). Treatment recommendations were affected in 12 cases, 10 of whom were offered investigational therapy. CONCLUSIONS: Although a liver biopsy may help to definitively establish the final diagnosis in patients, the results alter the presumptive prebiopsy diagnosis infrequently, and no proven therapy exists for the vast majority of these patients. Therefore, the risks and benefits of a liver biopsy should be carefully weighed, especially in settings in which investigational therapies are unavailable.