In vitro and in vivo neutralizing activity of human colostrum and milk against purified toxins A and B of Clostridium difficile

The neutralizing activity (NA) of supernates of colostral samples collected postpartum from 55 women and tested against a 50% cytopathic dose of purified toxins A and B of Clostridium difficile was evaluated in Y1 adrenal cells. Thirty-one (56%) of the samples had NA against one or both toxins. Samples of breast milk were collected postpartum from five women-three had colostral NA and two did not. All milk specimens from the three women with colostral NA had NA titers of 1:1-1:4 throughout the study (609 days in one case). Samples from the two women without colostral NA did not exhibit NA during a 60-day follow-up period. In suckling mice either toxin plus human milk with in vitro NA elicited significantly less fluid accumulation than did toxin plus diluent or toxin plus milk without in vitro NA (P less than .025 to P less than .05). Twelve (63%) of 19 milk samples with in vitro NA against toxin A and 15 (65%) of 23 with in vitro NA against toxin B inhibited fluid accumulation caused by the corresponding toxin. In vitro NA against toxin A appeared to reside in the secretory IgA fraction of one milk sample assessed by immune precipitation. The results suggest that human milk may protect newborn infants against toxins A and B of C. difficile.     

Diurnal variations and within the feed in lactose and oligosaccharides of human milk

Variations of lactose and oligosaccharides in human milk were studied during the day and the feed, by dialysis, chromatography on Bio-gel P-2 column, paper chromatography, colorimetric analysis and gas chromatography. Progressive changes were found during the day, but not during the feed. A diurnal variation in milk lactose was seen, which was the inverse of the oligosaccharides. Significant negative correlations between lactose and oligosaccharides were seen in the afternoon and evening (p less than 0.05). The minimal mean value of lactose at 19.00 h is 58.64 +/- 5.28 g/l and the maximal mean values of oligosaccharides was 17.93 +/- 2.28 g/l. The data are discussed with regard to other milk constituents and to their possible physiological relevance.     

Double blind study of milk lactose intolerance.

One hundred and fifty subjects were studied in a double blind fashion to determine the relationship between lactose malabsorption and milk lactose intolerance. Each participant received 250 ml of a different type of milk on 3 consecutive days. Milk A contained no lactose, milk B had 12.5 g, and milk C contained 37.5 g of lactose. After the experiment was completed each subject was classified with a lactose tolerance test as having "sufficient" or "insufficient" lactase activity. Milk A produced no gastrointestinal symptoms in either sufficient or in insufficient persons. Milk B produced symptoms in 3.8% of sufficient and 37.1% of insufficient individuals, and Milk C induced symptoms in 7.6% of sufficient and 83.5% of insufficient subjects. These differences are very highly significant (P less than 0.0001). It is concluded that lactose-intolerant subjects are indeed milk-intolerant and that the frequency with which symptoms occur in persons with lactose malabsorption increases in direct relation to the lactose content of the milk.     

Passive protective activities of human sera against infection with strain ST67P of Staphylococcus hyicus

Five tenths ml of passive protective antibodies in 100 samples of normal human sera against challenge with an encapsulated strain ST67P of Staphylococcus hyicus in mice were examined. Thirty three of them passively protected in mice against infection with strain ST67P of S. hyicus. The activities were sensitive to 2-mercaptoethanol and were absorbed out either with rabbit anti-human IgG, IgM or IgA serum. Also, the serum activities were absorbed out with cell surface polysaccharide extracted from the cell surface substance of the strain. When passive protective human serum was absorbed out with cell surface polysaccharide, reduction of IgG, IgA and IgM contents were 14.48, 19.49 and 33.3 percent, respectively, while 2.17, 4, 55 and zero in non protective human serum. These results indicate that the protective activities against strain ST67P were specifically related to IgM globulin against the above cell surface polysaccharide.     

Effects of fucosylated milk of goat and mouse on Helicobacter pylori binding to Lewis b antigen

AIM:To evaluate the effects of animal milk containing fucosylated antigens on Helicobacter pylori (H pylon) binding to Lewis b antigen.METHODS:A mammary gland expression vector containing human α1-3/4-fucosyltransferase cDNA sequences was constructed. Transient expression of human(α1-3/4-fucosyltransferase cDNA in goat mammary cell and establishment of transgenic mice were performed. The adhesion inhibitory properties of milk samples were analyzed by using Hpylori.RESULTS: Goat milk samples were found to inhibit bacterial binding to Lewis b antigen. The highest inhibition was observed 42 h after injection of the plasmid. The binding activity of Hpylori to Lewis b antigen reduced mostly, by 83%, however milk samples from transgenic mice did not inhibit Hpylori binding to Lewis b antigen.CONCLUSION: The use of “humanized“ animal milk produced by the transgenic introduction of fucosylated antigen can perhaps provide an alternative therapy and preventive measure for Hpylori infection.     

Influence of long-term injection sclerotherapy on portal venous component of total liver perfusion measured by hepatosplenic radionuclide angiography

In an attempt to establish whether repeated injection sclerotherapy (ST) has any influence on the portal venous fraction of hepatic blood flow, we investigated 8 patients with liver cirrhosis and esophageal varices immediately prior to and six months after ST, using computerized hepatosplenic radionuclide angiography. The mean values of the portal venous fraction of the hepatic blood flow before and after treatment did not differ (20 +/- SD 9% vs. 20 +/- 11%). Eight cirrhotics with esophageal varices who had received no ST served as controls. Also in these patients, the mean values did not change over a period of six months (17 +/- 10% vs. 17 +/- 14%). The mean portal venous fraction of hepatic blood flow was significantly higher (56 +/- 9%, p less than 0.001) in 10 subjects without hepatobiliary disease. The results show that while the portal venous fraction of hepatic blood flow is significantly reduced in patients with liver cirrhosis and esophageal varices, it is not influenced by ST.     

Lactase deficiency and lactose intolerance-related symptoms in adult healthy subjects from western France]

The prevalence of lactase deficiency (LD) and lactose intolerance is not well known in France. Using breath hydrogen and methane analysis after 50 g oral lactose load, we investigated the prevalences of LD, lactose intolerance, and methane producer status in 102 healthy adults born in western France, and we examined the relationships between these parameters and the daily milk consumption. In 10 subjects with LD and lactose intolerance, we studied the reproducibility of the lactose hydrogen breath test results for the diagnosis of LD and lactose intolerance and estimated the quantity of lactose malabsorbed in comparison with the lactulose hydrogen breath test. The prevalence of LD was 23.4 percent and symptoms of lactose intolerance were observed in 50 percent of the 24 subjects with LD. The daily milk consumption was not significantly different in the 24 subjects with LD and in the 78 subjects without LD (281 +/- 197 vs 303 +/- 217 ml/24 h). The prevalence of methane producer status was 42.1 percent. The symptomatic group of lactose malabsorbers (n = 12) was characterized by a shorter lactose mouth to caecum transit time (39 +/- 20 vs 88 +/- 48 min; P less than 0.05), and more marked hydrogen production (6.1 +/- 2.3 vs 3.4 +/- 2.4 10(3) ppm.min; P less than 0.04). In the 10 subjects with LD and lactose intolerance, the hydrogen breath test was reproducible for diagnosis of LD and lactose intolerance, and for hydrogen production. The quantity of lactose malabsorbed was 60 percent. In France, symptoms of lactose intolerance are not severe and do not affect the daily consumption of milk and dairy products.     

Glycosylation changes in human chorionic gonadotropin and free alpha subunit as gestation progresses.

Carbohydrate is important to the structure, function, and circulatory survival of the glycoprotein hormones. Human CG (hCG) and the related free alpha-molecule of pregnancy contain four and two asparagine-linked oligosaccharides, respectively. The present study analyzes changes in the glycosylation patterns of hCG and free alpha in early vs. late gestation. Five volunteers provided 24-h urine samples, weekly, throughout their pregnancies. Extracts of early pregnancy (weeks 7-12) and late pregnancy (weeks 28-32) urines were pooled. Early and late samples from each patient were subjected to gel filtration to separate hCG and free alpha, and the populations thus obtained were analyzed by lectin affinity chromatography on Concanavalin A-Sepharose (Con A) and Lens culinaris-agarose (Lch). Using Con A, free alpha and hCG were separated into an unbound fraction (eluted with Con A buffer), a weakly bound fraction (eluted with 10 mmol alpha-methyl-D-glucoside) and a tightly bound fraction (eluted with 500 mmol alpha-methyl-D-mannoside). For free alpha-molecule, a significant decrease in tightly bound Con A forms, was noted from early to late pregnancy with a mean difference of 17.0 +/- 2.4% (P less than 0.01). Concomitantly, in late pregnancy, an increase in Con A unbound forms of free alpha was noted with mean difference of 12.5 +/- 1.7% (P less than 0.01). These changes indicate the presence of more highly branched oligosaccharides on free alpha as gestation advances. No changes were noted in the Con A binding of intact hCG; nearly all hCG bound in both early and late pregnancy. Using Lch, free alpha and hCG were separated into an unbound fraction (eluted with Lch buffer) and a bound fraction (eluted with 500 mmol alpha-methyl-D-mannose). Both free alpha and intact hCG in late pregnancy exhibited increased binding to Lch, with mean differences from early to late pregnancy of 30.2 +/- 4.8% (P less than 0.01) and 11.4 +/- 4.5% (P less than 0.05), respectively. These data indicate increased incorporation of fucose into the carbohydrate moieties in late pregnancy. Taken together, these data derived by analysis using lectin specificity imply the presence of more highly branched, fucosylated oligosaccharides as gestation progresses.     

Lactation is disrupted by alpha-lactalbumin deficiency and can be restored by human alpha-lactalbumin gene replacement in mice.

Mice carrying either a deletion of the murine alpha-lactalbumin (alpha-lac) gene (null allele) or its replacement by the human alpha-lac gene (humanized allele) have been generated by gene targeting. Homozygous null females are alpha-lac-deficient, produce reduced amounts of thickened milk containing little or no lactose, and cannot sustain their offspring. This provides definitive evidence that alpha-lac is required for lactose synthesis and that lactose is important for milk production. Females homozygous for the humanized allele lactate normally, indicating that human alpha-lac can replace murine alpha-lac. Mouse and human alpha-lac expression was compared in mice heterozygous for the humanized allele. The human gene expressed approximately 15-fold greater mRNA and approximately 14-fold greater protein than the mouse, indicating that the major determinants of human alpha-lac expression are close to, or within, the human gene and that the mouse locus does not exert a negative influence on alpha-lac expression. Variations in alpha-lac expression levels in nondeficient mice did not affect milk lactose concentration, but the volume of milk increased slightly in mice homozygous for the humanized allele. These variations demonstrated that alpha-lac expression in mice is gene dosage dependent.     

Binding of thyrotropin to lentil lectin is unchanged by thyrotropin-releasing hormone administration in three patients with thyrotropin-producing pituitary adenomas.

Glycoproteins have increased affinity for lentil lectin when fucose residues are bound to N-acetylglucosamine in the "core region" of their asparagine-linked oligosaccharides. In three patients with thyrotropin (TSH)-producing pituitary tumors, the proportion of serum TSH isoforms that bound to lentil (70.8% +/- 15%) was higher than that seen for TSH from normal persons (32.5 +/- 8%). Unlike normal subjects, the concentration of TSH circulating in the tumor patients after acute administration of TSH-releasing hormone (TRH) did not rise, and the TSH did not exhibit increased binding to lentil compared to basal TSH. The TSH binding to lentil in one tumor patient decreased after metoclopramide, but TSH binding to lentil generally remained unchanged after metoclopramide or L-dopa administration. We conclude that human thyrotropic tumor tissue, unlike normal thyrotrophs, generally fails to release more highly fucosylated isoforms of TSH after pharmacologic stimulation, perhaps because the tumor tissue is less readily modulated by endocrine stimuli, or because the TSH is already relatively highly fucosylated.     

Effect of hypertensive plasma on Ca2+ transport in human neutrophils

The effects of plasma fractions from essential hypertensives (n = 17) and normotensives (n = 17) on Ca2+ transport in permeabilised human neutrophils were studied using an ion-selective electrode. The plasma fractions were obtained by gel filtration and contained substances with a molecular weight in the range of 1000-1500 Da. When isolated from essential hypertensives, this fraction had been shown to increase blood pressure after intravenous injection in the rat. The rate of Ca2+ uptake by permeabilised neutrophils after addition of extracellular Ca2+ was significantly accelerated during incubation of the cells with the hypertensive fraction (855.9 +/- 812.3% vs 218.0 +/- 294.3% of the control value, P less than 0.05). In a suspension with intact neutrophils hypertensive plasma fractions (n = 7) caused an increase of extracellular pCa by 0.479 +/- 0.115 (P less than 0.01), whereas the normotensive fractions did not change pCa significantly. It is concluded that the hypertensive plasma fraction increases Ca2+ accumulation in subcellular particles. Additionally the Ca2+ influx through the plasma membrane is increased by the circulating hypertensive factor.     

Ruthenium red delays the onset of cell death during oxidative stress of rat hepatocytes.

Our objective was to determine if ruthenium red protects against lethal oxidative injury of rat hepatocytes. tert-Butyl hydroperoxide, 100 mumol/L, was used to produce oxidative stress. After 2 hours of oxidative stress, cell viability was greater with than without 25 mumol/L ruthenium red (37% vs. 4.6%; P less than 0.01). Despite this cytoprotection, ruthenium red did not alter the rate or extent of glutathione depletion, malondialdehyde generation, or adenosine triphosphate depletion. In contrast, ruthenium red did retard loss of the mitochondrial membrane potential (78% vs. 42% within 30 minutes; P less than 0.01). However, the protective effect of ruthenium red could not solely be explained by preserving the mitochondrial membrane potential. Indeed, ruthenium red still improved cell survival after 2 hours of exposure to 10 mumol/L carbonyl cyanide m-chlorophenylhydrazone (CCCP), a mitochondrial uncoupler (39% vs. 13%; P less than 0.01). Cytosolic free calcium values did not change during the uncoupling of mitochondria, suggesting that the cytoprotective properties of ruthenium red cannot be explained by blocking mitochondrial calcium transport. Ruthenium red did inhibit proteolysis after 2 hours of exposure to tert-butyl hydroperoxide (434 +/- 62 vs. 242 +/- 20 nmol/10(6) cells; P = 0.016) or CCCP (236 +/- 50 vs. 99 +/- 38 nmol/10(6) cells; P = 0.04). The results indicate that ruthenium red appears to protect against hepatocellular injury by inhibiting degradative proteolytic activity. It is concluded that proteolysis may be an important mechanism contributing to lethal oxidative injury of hepatocytes.     

Prognostic significance of ST segment depression in lateral leads I, aVL, V5 and V6 on the admission electrocardiogram in patients with a first acute myocardial infarction without ST segment elevation

OBJECTIVES

We sought to investigate the short-term prognostic value of the admission electrocardiogram (ECG) in patients with a first acute myocardial infarction (MI) without ST segment elevation.

BACKGROUND

ST segment depression on hospital admission predicts a worse outcome in patients with a first acute MI, but the prognostic information provided by the location of ST segment depression remains unclear.

METHODS

In 432 patients with a first acute MI without Q waves or ≥0.1 mV of ST segment elevation, we evaluated the ability of the initial ECG to predict in-hospital death.

RESULTS

The presence, magnitude and extent of ST segment depression were associated with an increased mortality, but the only electrocardiographic variable that was significant in predicting death after adjusting for baseline predictors was ST segment depression in two or more lateral (I, aVL, V₅, or V₆) leads (odds ratio 3.5, 95% confidence interval 1.2 to 10.6). Patients with lateral ST segment depression (n = 91, 21%) had higher rates of death (14.3% vs. 2.6%, p < 0.001), severe heart failure (14.3% vs. 4.1%, p < 0.001) and angina with electrocardiographic changes (20.0% vs. 11.6%, p = 0.04) than did the remaining patients, even though they had similar peak creatine kinase, MB fraction levels (129 ± 96 vs. 122 ± 92 IU/liter, p = NS). In contrast, ST segment depression not involving the lateral leads did not predict a poor outcome. Among patients who were catheterized, those with lateral ST segment depression had a lower left ventricular ejection fraction (57 ± 12% vs. 66 ± 13%, p = 0.001) and more frequent left main coronary artery or three-vessel disease than did the remaining patients (60% vs. 22%, p < 0.001).

CONCLUSIONS

In patients with a first non–ST segment elevation acute MI, ST segment depression in the lateral leads on hospital admission predicts a poor in-hospital outcome.     

Prognostic significance of ST segment depression in lateral leads I, aVL, V5 and V6 on the admission electrocardiogram in patients with a first acute myocardial infarction without ST segment elevation

OBJECTIVESWe sought to investigate the short-term prognostic value of the admission electrocardiogram (ECG) in patients with a first acute myocardial infarction (MI) without ST segment elevation.BACKGROUNDST segment depression on hospital admission predicts a worse outcome in patients with a first acute MI, but the prognostic information provided by the location of ST segment depression remains unclear.METHODSIn 432 patients with a first acute MI without Q waves or ≥0.1 mV of ST segment elevation, we evaluated the ability of the initial ECG to predict in-hospital death.RESULTSThe presence, magnitude and extent of ST segment depression were associated with an increased mortality, but the only electrocardiographic variable that was significant in predicting death after adjusting for baseline predictors was ST segment depression in two or more lateral (I, aVL, V₅, or V₆) leads (odds ratio 3.5, 95% confidence interval 1.2 to 10.6). Patients with lateral ST segment depression (n = 91, 21%) had higher rates of death (14.3% vs. 2.6%, p < 0.001), severe heart failure (14.3% vs. 4.1%, p < 0.001) and angina with electrocardiographic changes (20.0% vs. 11.6%, p = 0.04) than did the remaining patients, even though they had similar peak creatine kinase, MB fraction levels (129 ± 96 vs. 122 ± 92 IU/liter, p = NS). In contrast, ST segment depression not involving the lateral leads did not predict a poor outcome. Among patients who were catheterized, those with lateral ST segment depression had a lower left ventricular ejection fraction (57 ± 12% vs. 66 ± 13%, p = 0.001) and more frequent left main coronary artery or three-vessel disease than did the remaining patients (60% vs. 22%, p < 0.001).CONCLUSIONSIn patients with a first non–ST segment elevation acute MI, ST segment depression in the lateral leads on hospital admission predicts a poor in-hospital outcome.     

Short-term and long-term prognosis after myocardial infarction: prognostic value of coronary anatomy and left ventriculography

To assess prospectively short-term (1 year) and long-term (4 years) prognostic variables from heart catheterization, 325 consecutive patients of 65 years or less who survived a myocardial infarction were studied. In all coronary angiography and left ventriculography was performed 4-6 weeks after infarction. First year mortality rate was significantly higher in patients with an ejection fraction less than 0.30 (20%) than in patients with an ejection fraction greater than or equal to 0.30 (2%, P less than 0.001). During 4-year follow-up cumulative mortality was 44% in patients with an ejection fraction less than 0.30 vs 11% in patients with an ejection fraction greater than or equal to 0.30 (P less than 0.001). In patients who survived the first year after infarction, however, a low ejection fraction less than 0.30 was not associated with higher mortality rate during the subsequent 3 years. Mortality in patients with one-, two- or three-vessel disease was equally distributed in the first year. After 4 years patients with three-vessel disease had a significant higher mortality (32%) than patients with two- or one-vessel disease (12 and 11%, respectively; P less than 0.05). Reinfarction rate was higher in patients with an ejection fraction less than 0.30 (14%) than in patients with an ejection fraction greater than or equal to 0.30 (3%, P less than 0.05) in the first year. During 4-year follow-up reinfarction rate was 38% in patients with an ejection fraction less than 0.30 vs. 13% in patients with an ejection fraction greater than or equal to 0.30 (P less than 0.05). Again, in patients who survived the first year without reinfarction, an ejection fraction less than 0.30 had no prognostic value for recurrent myocardial infarction during the subsequent three years. Three-vessel disease had no higher reinfarction rate in the first year of follow-up: during 4 years, patients with three-vessel disease had a reinfarction rate (32%) compared to patients with two- and one-vessel disease (14 and 11%, respectively; P less than 0.05). It is concluded that an ejection fraction less than 0.30 is a major risk factor for cardiac death and reinfarction only in the first year after myocardial infarction. Beyond the first year, a subgroup of patients with three-vessel disease is at risk for both cardiac death and reinfarction during the three subsequent years.     

Does the discharge ECG provide additional prognostic insight(s) in non-ST elevation ACS patients from that acquired on admission?

BACKGROUND: Although the prognostic value of admission ST changes in patients with non-ST elevation acute coronary syndrome (ACS) is established, the utility of the discharge ECG is unknown. Accordingly, using the PARAGON-B Troponin substudy, we assessed the prevalence of ST depression on both admission and discharge ECG, the likelihood of developing new Q-waves at discharge and the additional prognostic value of these changes. METHODS AND RESULTS: Nine hundred and eighteen patients were studied; 542 patients (59%) had admission ST downward arrow > or =1mm and 376 patients (41%) did not and their 6-month mortality was 4.4 vs 0.8%, P=0.002, respectively. Of patients with ST downward arrow on admission, 320 (59%) normalized their ST segment at discharge. Of patients without ST downward arrow on admission, 35 (9.3%) developed new ST downward arrow at discharge. Patients with persistent ST downward arrow on discharge had a higher 6-month mortality (6.0 vs 0.9%), (re)MI (16.3 vs 7.4%), and death/(re)MI (20.0 vs 8.3%) than those who never had ST downward arrow (all P< or =0.002). Two hundred and fifty-six patients had Q-waves on admission whereas by discharge 320 had Q-waves. Patients with Q-waves on discharge vs those without had a higher mortality (4.8 vs 1.9%), (re)MI (13.8 vs 8.3%), and death/(re)MI (16.4 vs 9.6%) at 6 months (all P< or =0.021). CONCLUSIONS: This study highlights that the dynamic ECG changes which occur between admission and discharge in non-ST elevation ACS patients allows further risk stratification in determining the likelihood of 6-month death and/or re(MI).     

Calcium absorption from milk in lactase-deficient and lactase-sufficient adults

To determine whether lactose influences the absorption of calcium, the uptake of calcium from lactose-hydrolyzed milk and from unhydrolyzed milk was measured in 20 adults: 10 were lactase-deficient and 10 were lactase-sufficient as defined by breath hydrogen test, plasma glucose determination after oral lactose dose, and presence or absence of symptoms after lactose ingestion. On different days, each subject received either lactose-hydrolyzed or unhydrolyzed milk. Calcium absorption was measured by a double-isotope technique. In the lactase-deficient group, the mean absorptions were 33.5% from hydrolyzed milk and 36.2% from the same volume of unhydrolyzed milk (P greater than 0.30). In the lactase-sufficient group, mean absorptions were 24.2% from hydrolyzed milk and 25.7% from unhydrolyzed milk. The mean calcium absorption from both lactose-hydrolyzed milk and unhydrolyzed milk was significantly greater (P less than 0.01) in the lactase-deficient group compared to the lactase-sufficient group, presumably reflecting lower dietary calcium intake in the former. These data indicate that, in lactase-deficient subjects, malabsorption of lactose does not affect calcium absorption.     

Effect of age on long-term prognosis of patients with myocardial infarction

We studied 181 patients aged under 65 years and 129 patients over 65 with acute myocardial infarction. There were no major differences in the prevalence of coronary risk factors, angina or previous myocardial infarction. A larger percentage of elderly patients had congestive heart failure (51.4% vs 32.6%, P less than 0.001) and complete heart block (17.1% vs 7.2%, P less than 0.01) during the acute phase. In-hospital mortality was significantly higher in the elderly patients (34% vs 16%, P less than 0.01). Late mortality rates correlated in both groups with the Killip class at the time of infarction and with the occurrence of reinfarction. In the elderly group, it was also associated with complete heart block during the acute phase. Five-year survival was 80% in the older and 72% in the younger patients (P = 0.1). Age did not affect survival of Killip class I patients (85% vs 86%, P = 0.83), but life expectancy was significantly reduced in elderly patients in Killip class greater than II (39% vs 60%, P less than 0.05). In conclusion, elderly patients cannot be considered a homogeneous group of high-risk patients. Clinical variables at the time of infarction can identify low- and high-risk subsets among them. Age constitutes an independent prognostic factor for late mortality when any degree of heart failure is present.     

High-risk subgroups of patients with non-Q wave myocardial infarction based on direction and severity of ST segment deviation

To determine the significance of the direction of ST segment deviation on admission of patients who evolved non-Q wave myocardial infarction (MI), 97 patients with initial ST segment depression were compared to 207 patients with initial ST segment elevation. Patients with ST segment depression developed smaller infarcts than those with ST segment elevation (creatine kinase MB isoenzyme 8.2 vs 13.3 gmEq/m2, p less than 0.002), but had a lower left ventricular ejection fraction on admission (44% vs 51%, p less than 0.001), more in-hospital complications, and a higher cumulative 1-year mortality (29% vs 11%, p less than 0.001) that could be accounted for by an excess of adverse baseline characteristics. Although a severity index (combining magnitude and extent of the initial ST segment deviation) was not useful for discriminating prognosis of patients with non-Q wave MI who presented with ST segment depression, it was useful in identifying a subgroup of patients with ST segment elevation with an adverse prognosis. The poor outcome of patients with non-Q wave MI presenting with either ST segment depression or severe ST segment elevation on admission suggests that patients in these subgroups should receive close surveillance and should possibly be considered for aggressive therapy.     

"Tombstoning" of ST segment in acute myocardial infarction -- effect on clinical course

INTRODUCTION: There are many reports evaluating the effects of the amplitude of ST segment elevation in acute myocardial infarction with ST segment elevation (STEMI) on infarction zone and course. There are, however, few publications dealing with the effects of ST segment elevation shape in STEMI patients on their clinical course and prognosis. AIM: Assessment of the rate of "tombstoning" of ST segment (TOMB-ST) in STEMI patients and the effects on their clinical outcome. METHODS: The study involved 207 consecutive patients with STEMI hospitalised in the period 2000-2002 analysed with respect to the in-hospital complication rate. RESULTS: On admission, TOMB-ST was observed in 55 (26.1%) subjects. TOMB-ST was more common in anterior MI (39.8%) than in inferior MI (10.6%). Patients with TOMB-ST compared to non-TOMB-ST ones had a significantly higher mortality rate (38.2% vs 9.9%, p <0.001), heart failure (45.6% vs 28.3%, p <0.026), ventricular fibrillation (18.1% vs 6.4%, p <0.016), and lower left ventricular ejection fraction (40.9% vs 48.6%, p <0.001). The sum of amplitudes of ST segment deviations (SigmaST) >20 mm was indicative for the subgroup of patients with TOMB-ST and trend towards higher mortality (40% vs 30%, NS). However, in patients without TOMB-ST, SigmaST >20 mm identified two subgroups with significantly different mortality rates (20% vs 4%, p=0.001). CONCLUSIONS: TOMB-ST was observed in one fourth of patients with STEMI. This abnormality was associated with an increased mortality rate, higher incidence of heart failure and ventricular fibrillation as well as decreased left ventricular ejection fraction. In the population with TOMB-ST, increased mortality was independent of the total amplitude of ST segment displacement; this relation was, however, observed in patients with STEMI without TOMB-ST.