Central haemodynamics in acute myocardial infarction in relation to mortality and peak enzyme activity

The relation of central haemodynamic changes to subsequent mortalityand peak enzyme activity was investigated in 190 patients withacute myocardial infarction. The mean delay time from onsetof symptoms to the haemodynamic study was 7.2 hours. Major exclusioncriteria were heart rate < 65beats min^–1, systolicblood pressure < 105 mmHg and lung rales to a distance of> 10 cm above the lung bases. Nine patients (4.7%) died within15 days and 16 patients (8.4%) within 90 days after the infarction.Compared to survivors, non-survivors were characterized by baselinedepression of cardiac index, stroke volume index and left ventricularstroke work index, while pulmonary capillary wedge pressureand peripheral resistance were increased. However, a wide overlapbetween survivors and non-survivors makes the predictive valuelow in the individual patient. Peak serum aspartate aminotransferase (S-ASAT) activity wasweakly related to baseline pulmonary capillary wedge pressure(r = 0.28; P< 0.001) and stroke volume index (r = –0.22;P7lt;0.01). The correlation to pulmonary capillary wedge pressurewas only found in anterior (r = 0.34) infarcts. Peak serum lactatedehydrogenase (LD¹) was not correlated with baseline haemodynamics.     

The transition from injecting to smoking heroin in three Spanish cities

Aims. To measure the current prevalence of different routes of heroin administration among users and to describe the most frequent patterns in the evolution of the main route from the time of first use to the present and their implications for the control of the HIV epidemic. Design. Cross-sectional study. Face-to-face interviews using a structured questionnaire. Setting and participants. Nine hundred and nine regular heroin users from Madrid, Barcelona and Seville (about 300 per city), half of them recruited in treatment centres and the other half out of treatment. Measurements. Socio-demographic characteristics, current and historical behaviours related to route of administration. Findings. Before 1980 injection was the first main route of heroin administration for most users in Barcelona and Madrid; in Seville smoking already predominated, although 40% of users began by injecting. Sniffing subsequently became predominant in Barcelona, while smoking became the predominant first route in Madrid and Seville (smoking has been the only first route in Seville since 1991). The prevalence of injection as the main route of administration during the last 30 days was 77.3% in Barcelona, 24.3% in Madrid and 23.9% in Seville; smoking predominated in the latter two cities. The factors most strongly associated with injection as the preferred route were city of recruitment and having a partner who injected. Some 73% of those who stopped injecting in their last change of route stated that the results of their HIV test or fear of becoming infected had been important in making this decision. Conclusions. The change from injecting to smoking will greatly facilitate the control of HIV infection in Spain. However, the main causal factor does not appear to be the perception of HIV risk, but rather other, ecological factors (cultural or market-related). The absence of these factors in some areas may impede the spread of smoking.     

Multicentre randomized trial of sotalol vs amiodarone for chronic malignant ventricular tachyarrhythmias

Sotalol was compared with amiodarone in this open randomizedmulticentre study of patients with ventricular tachycardia orfibrillation not associated with acute myocardial infarctionrefractory to or intolerant of Class I drugs. 16 of 30 patientstreated with amiodarone completed 12 months on therapy, fivewere withdrawn because of recurrent ventricular tachycardiaand nine because of presumed adverse drug reactions, complianceproblems or protocol violation. Four of those who were withdrawndied within 12 months. Sixteen of 29 patients completed 12 months on sotalol, one waswithdrawn because of ventricular tachycardia and nine becauseof presumed adverse drug reactions, poor compliance or the needfor coronary artery surgery. Three died on treatment and twoafter withdrawal but within 12 months of entering the study. When the results are analysed by intention to treat there wasno significant difference in antiarrhythmic efficacy or in theincidence of side-effects severe enough to warrant withdrawalfrom the trial. There was an increase in left ventricular ejectionfraction in those treated with sotalol, which, because of itspharmacokine-tics, is an attractive alternative to amiodaronefor patients with malignant ventricular arrhythmias who cantolerate ß-adrenergic blockade.     

Prevention of coronary heart disease: how far is the Belgian population from the recommended nutritional goals and ideal serum cholesterol levels?

For 15 years, recommendations concerning the primary preventionof coronary heart disease (CHD) have been made by internationalbodies or national agencies. In a national Belgian nutritionalstudy (the B.I.R.N.H. Study), the authors review how far theBelgian population is from the recommended nutritional goalsand ideal serum cholesterol. They also make comparisons betweengenders and look at differences according to the linguisticbackground (French- or Dutch-speaking subjects). Only a small percentage of the Belgian population reach thenutritional goals for total fat intake in males (8.4%) and females(7%), saturated fat intake (7.0% and 6.2%, respectively), andP/S ratio (13.5% and 12.4%, respectively). The percentages reachingnutritional goals are somewhat higher for polyunsaturated fatintake (27.9% and 28.6%, respectively) and dietary cholesterol(39.4% and 54.6% respectively). A total of 29.9% of the male population, and 32.7% of the femalepopulation are at ‘high risk’ of CHD according totheir serum cholesterol levels. In general the results are betterfor the Dutch-speaking population than for their French-speakingcounterparts. In conclusion, despite modifications in eating patterns anda decrease in CHD mortality in Belgium during the 1970s, a veryhigh percentage of males and females are still far from therecommended nutritional goals and ideal serum cholesterol levels.     

AN OPEN MULTICENTRIC STUDY EVALUATING 4-HYDROXYBUTYRIC ACID SODIUM SALT IN THE MEDIUM-TERM TREATMENT OF 179 ALCOHOL DEPENDENT SUBJECTS

We report the results of an ‘open’ multicentre studyevaluating the use, tolerability and therapeutic efficacy ofthe sodium salt of 4-hydroxybutyric acid (GHB) for the medium-termtreatment of withdrawal symptoms in 179 patients with alcoholdependence followed up as outpatients. The follow-up of patientswas 6 and 12 months after drug discontinuation. Following adaily oral administration of 50mg/kg for approximately 6 months,no serious systemic or single-organ consequences leading todrug discontinuation were reported, and tolerability was fairin all patients. Eleven subjects (10.1%) snowed craving forthe drug and voluntarily increased their doses (6–7 timesthe recommended levels). GHB led to complete abstinence duringdrug administration in 78.0% of the patients. A significantreduction of compulsive desire (‘craving’) was observedin parallel, as deduced from evaluation of a specific questionnaire,the Alcohol Craving Scale. At follow-up examination, 43 of thetreated subjects remained abstinent at 6 months, and 30 subjectswere abstinent for 1 year after drug discontinuation.     

Comparison of the efficacy, safety, and tolerability of propiverine and oxybutynin for the treatment of overactive bladder syndrome

AIM: To compare the effects of propiverine and oxybutynin on ambulatory urodynamic monitoring (AUM) parameters, safety, and tolerability in patients with overactive bladder. METHODS: This was a randomized, double-blind, placebo-controlled, multicentre, crossover study. Patients (n = 77) received two of the following treatments during two 2-week periods: propiverine 20 mg once daily, propiverine 15 mg three times daily, oxybutynin 5 mg three times daily, and placebo. AUM parameters, salivary flow, visual near point, and heart rate were assessed. RESULTS: A consistent order in the efficacy between active treatment groups was observed for the reduction in mean involuntary detrusor contractions (IDCs; oxybutynin 15 mg 相似文献   

Utilization of coronary angioplasty and cost of angioplasty disposables in 14 western European countries

An inventory has been made of the practice of angioplasty in14 European countries from 1985 onwards. The numbers of proceduresperformed varied in 1985 from 3 to 186 per million inhabitants,in 1991 from 52 to 716. All countries showed a steady increase,but the highest performer, Belgium, achieved only 55% of thenumber of angioplasties performed in 1991 in the U.S.A. No relationwas found between the number of angioplasties and death ratefor ischaemic heart disease, national income, number of cardiologistsor spending on health care. The number of catheterization laboratorieswas related to the number of procedures. Prices of angioplasty disposables varied widely between countries.In 1989 Italy and Spain had very high costs, averaging almost2500 ECU and 2000 ECU for ACS and Schneider balloon cathetersrespectively, while Switzerland and the U.K. were cheap withcosts between 700 ECU and 500 ECU for the same products. In1991 average prices for balloon catheters fell by 25% in Spain,while in Switzerland average prices increased by 10%, bringingthe almost four-fold price difference in 1989, down to a differenceof 2.5 in 1991. If the U.S.A. is taken as a standard and set against the deathrate from ischaemic heart disease in Western Europe in 1991the number of ‘missing’ angioplasties was 215 500,the U.K. accounting for 42% of this deficit.     

Time course of left ventricular function and coronary patency after saruplase vs streptokinase in acute myocardial infarction

As part of a prospective randomized double-blind trial (PRIMI)to study the early patency rate of the infarct-related arteryafter saruplase (INN for recombinant unglycosylated full-lengthhuman single-chain urokinase-type plasminogen activator) vsstreptokinase in a subgroup of patients, left ventricular functionwas compared between both treatment groups at 90 min and 24h after thrombolysis and at discharge, and ventricular functionwas related to the coronary perfusion grade. Despite a higher patency rate in the saruplase group 60 minafter initiating thrombolysis, neither global ejection fractionnor hypokinesia at the infarct site were significantly differentbetween the treatment groups at any of the three time pointswhen function was measured. Hypokinesia at the infarct siteremained almost equally severe throughout the study in patientswith perfusion grade O, I, and II, and was consistently significantlymilder in patients with perfusion grade III. In contrast, inpatients with perfusion grade II there was a significant dropin hyperkinesia at the opposite wall at 24 h after thrombolysisand before discharge despite unchanged wall motion at the infarctsite. Although patients treated with saruplase had a higher patencyrate in the infarct related vessel shortly after the start ofthrombolysis, no difference was found in left ventricular functioncompared to patients treated with streptokinase. Complete reperfusion(TIMI grade III) seems to be a prerequisite for left ventricularfunction recovery after thrombolysis, whereas only an occludedvessel (TIMI grade O and I) seems to be related to a longerlasting hyperkinesia at the opposite wall.     

Detection of gram-negative bacteraemia in early sepsis by a quantitative chromogenic and kinetic endotoxin assay

A kinetic chromogenic limulus test was carried out in order to investigate the possibility of a sensitive and specific detection of circulating endotoxin during the first 24 h of septic shock or severe sepsis in 76 patients. Two commercial kits, Whittaeker (W) and Chromogenix (C), were used. Blood culture was taken as a reference. At 1 : 10 plasma dilution (a currently used dilution in the end point limulus test) abnormal reaction kinetics were found in 13% and 41% of tests, for C and W respectively ( P  = 0.0008), resulting in unreliable results. Retesting plasma at a greater dilution, until the reaction kinetic was identical to calibration curve control values, gave similar results between the two kits and a better accuracy. Beyond a 0.5 EU mL⁻¹ endotoxin level, the probability of Gram-negative bacteraemia was high (sensitivity = 0.53 and 0.47; specificity = 0.95 and 0.93 for C and W respectively). This kinetic limulus amoebocyte lysate (LAL) test may be useful in therapeutic decisions for treatment of endotoxaemia.     

Operational factors of maternal mortality in Zimbabwe

Most studies on maternal mortality have looked at the directclinical causes and the distribution of actual rates. Much lessattention has been given to prevailing health care systems orcommunity factors associated with such deaths. A case-controlstudy design using incident cases was used to identify the magnitudeof maternal deaths and community and health care operationalfactors in both an urban and a rural setting in Zimbabwe. Thematernal mortality ratio for the rural setting was 168 per 100000 live births and that for the urban setting was 85 per 100000 live births. For the rural setting, the major direct causesof death were haemorrhage (24.8%), abortion complications (15.2%),puerperal sepsis (13.3%), and eclampsia (4.8%). For the urbansetting they were eclampsia (26.2%), abortion complications(23.0%), puerperal sepsis (14.8%) and haemorrhage (9.8%). Whereas rural-urban variations in maternal mortality were observed,inter-rural district variations were also apparent, especiallywith poor medical resources, poor communication and delayedinterventions. Risk factors for maternal mortality were presentat each of the various levels of care. Lack of antenatal care(ANC) had a significant Odds Ratio (OR 10.7 rural and 4.6 urban)contribution to maternal mortality. When abortions and ectopicswere excluded the OR for absent ANC was 4.1 (rural) and 2.6(urban). Lack of timely transport to nearest clinic or hospitaladversely affected pregnancy outcome in both rural and urbansettings. Despite delivery place planning, predisposing healthconditions and some danger signals, few of the women utilizedthe venue originally planned for delivery. Health education, community sensitization and teaching on risksignal awareness as well as health care delivery system strengtheningare recommended for reducing the high maternal mortality rates. ⁴Includes: Dr F Ashworth, Prof Mtimavalye, Dr Chatora, Dr PNhindiri, Dr Chiwora, Sister Nyangani, Sister Mujaji, SisterMakahamadzem, Mr Mandisodza, Mr Mashu, Sister Nyoni, Mr Dauramanzi,Mrs Dengu and the late Dr Chimbira