Lung function testing — useless in ventilated newborns?

Several methods have been used for lung function testing in the ventilated newborn. The interest in the field has been stimulated by the recent appearance of commercially available equipment for assessment of mechanical parameters and of functional residual capacity in this group. Nevertheless, lung function testing is rarely used as a clinical routine, even such simple variables as tidal volume and minute ventilation. Among the many possible reasons for this condition, the fragile nature of the infants and the hands-off policy usually exercised, the difficulties in measuring flow accurately, and the complexity of the present methods deserve special attention. In order to change this situation more work needs to be done to elucidate basal physiology of the ventilated lung and the relationships between ventilator settings, lung function and side-effects in different conditions. If then sufficiently simple, safe and accurate methods to assess the most important functions can be offered, lung function testing would be likely to become a useful component of routine care in future neonatal intensive care.     

Psychologists and tobacco: attitudes to cessation counseling and patterns of use

BACKGROUND: Psychologists can play an important role in helping their clients stop using tobacco. The extent to which they do so, or quit themselves, has not been reported previously. The utility of snus in reducing smoking prevalence is also questioned and merits study. METHOD: A 36-item self-completion questionnaire was mailed to a random sample of 1000 Swedish psychologists. RESULTS: The response rate was 85%. Very few psychologists (1%) 'often' helped clients to stop using tobacco. While a majority (72%) believed that quitting tobacco use would improve their client's quality of life, most (75%) thought that it was not their responsibility to help clients stop and 74% felt they lacked the necessary skills. About 8% of psychologists smoked cigarettes daily. Use of snus as an aid to cigarette cessation was common in men, but not women, although overall, the percentage of smokers who had quit smoking (72%) did not differ by gender. CONCLUSIONS: Most Swedish psychologists have stopped smoking, but very few help their clients to quit. Targeted campaigns aimed at encouraging and supporting psychologists to treat nicotine dependence are needed. This could increase cessation rates in the population. Snus helped reduce smoking prevalence among men and is a potentially useful harm reduction tool.     

Cardioprotection with beta-adrenoceptor blockers. Does lipophilicity matter?

Beta-blockers have several beneficial cardiovascular effects in patients with hypertension, angina pectoris, myocardial infarction, and congestive heart failure. In patients with myocardial infarction and congestive heart failure some beta-blockers have been found to reduce mortality and morbidity. The beta-blockers with a proven effect on prognosis include timolol, metoprolol, propranolol, bisoprolol, and carvedilol. One important question is whether all cardiovascular effects obtained by beta-blockers can be considered to be class effects. The beta-blockers with favorable effects on prognosis include two with more selective beta₁-receptor blockade (metoprolol and bisoprolol) and three non-selective (timolol, propranolol and carvedilol). One non-selective beta-blocker, which also has a more pronounced class III effect, sotalol, has been studied in a large postinfarction study without a significant effect on mortality. However, sotalol reduced the incidence of reinfarction similarly to the other beta-blockers with proven effect on mortality after myocardial infarction. Sotalol had no influence at all on sudden cardiac death, while all the other beta-blockers referred to above have a very marked effect on sudden cardiac death, in fact more marked than on overall mortality. The beta-blockers with proven effect on mortality and on sudden death have one property in common and that is some degree of lipophilicity. Sotalol and atenolol are hydrophilic. From animal experimental data it has been suggested that beta-blockers with some degree of lipophilicity penetrate into the brain and have an indirect effect on vagal activity, which is of importance for prevention of ventricular fibrillation and sudden cardiac death. It can be summarized that some beta-blockers have been found to reduce mortality and sudden cardiac death in patients after myocardial infarction and in congestive heart failure, while others have not. It seems that the major properties of the beta-blockers with proven effects on mortality and sudden cardiac death are beta₁-receptor blockade and some degree of lipophilicity. Until we know more about the mechanisms behind prevention of death and especially sudden cardiac death by beta-blockers, only drugs with proven effects on prognosis should be used.     

Long-term beta-blockade in dilated cardiomyopathy. Effects of short- and long-term metoprolol treatment followed by withdrawal and readministration of metoprolol

To evaluate the short- and long-term effects of beta-adrenergic blockade (metoprolol) as well as the reaction to withdrawal and readministration of metoprolol in severe heart failure, 33 patients (25 men and eight women; mean age, 47.6 +/- 14.0 years) with dilated cardiomyopathy were studied by right and left heart catheterization, right ventricular biopsy, two-dimensional and Doppler echocardiography, and external pulse recordings. Twenty-six of 33 patients survived more than 6 months, and 24 of the 26 patients improved their functional class (from mean 3.3 to 1.8, p less than 0.0001). These 24 patients were subjected to withdrawal of metoprolol until the number of symptoms increased and deterioration occurred as observed noninvasively (group 1, n = 16), whereas the eight patients did not deteriorate during a 12-month period (group 2). During long-term treatment with metoprolol, there was an increase in ejection fraction from 0.24 to 0.42 (p less than 0.0001), whereas there was a decrease in the left ventricular (LV) end-diastolic dimension (from 7.3 to 6.4 cm, p less than 0.0001), in the grade of mitral regurgitation (from 1.7 to 0.4, p less than 0.0001), and in the grade of tricuspid regurgitation (from 0.6 to 0.05, p less than 0.007). There was a decrease in pulmonary wedge pressure (from 23.8 to 10.7 mm Hg, p less than 0.0001), LV end-diastolic pressure (from 24.1 to 13.4 mm Hg, p less than 0.002), and systolic vascular resistance (from 1,782 to 1,499 dynes/sec/cm, p less than 0.04). There was an increase in systolic blood pressure (from 116 to 132 mm Hg, p less than 0.003), cardiac index (from 2.17 to 2.58 l/min/m2, p less than 0.005), and LV stroke work index (from 31 to 65 g.m/m2, p less than 0.0001). During withdrawal of metoprolol, the heart rate and left atrial dimension increased (p less than 0.0001), whereas ejection fraction decreased (p less than 0.0001). The 12 (of 16) patients in group 1 who survived the withdrawal period had metoprolol readministered, and subsequently, ejection fraction increased (from 0.23 to 0.33, p less than 0.002). Patients had a low number of ventricular beta-adrenergic receptors compared with healthy control subjects (30.3 +/- 2.9 vs. 97.4 +/- 8.7 fmol/mg protein, p less than 0.001), but long-term treatment with metoprolol caused a moderate up-regulation (from 30.3 +/- 2.9 to 49.0 +/- 7.1 fmol/mg protein, p less than 0.05), which may facilitate a more normal response to sympathetic stimulation.(ABSTRACT TRUNCATED AT 400 WORDS)     

Effect of long term treatment with metoprolol and sotalol on ventricular repolarisation measured by use of transoesophageal atrial pacing

The effects of long term (4 weeks) treatment with oral metoprolol (100 mg twice daily) and sotalol (160 mg twice daily) on ventricular repolarisation time were compared in a double blind crossover study in 20 patients post-infarction. For QT interval studies transoesophageal atrial pacing was performed at a cycle length of 800 ms. Sotalol prolonged the QT interval by 5-7% compared with metoprolol. The prolongation reflects a change in the repolarisation time because there was no change in the QS interval. Measurements of heart rate at rest and during bicycle exercise indicated that metoprolol and sotalol in the doses selected were equipotent as beta blockers. Transoesophageal atrial pacing is a simple non-invasive method with few and mild side effects that is well suited to drug studies.     

Localization of a functional autoimmune epitope on the muscarinic acetylcholine receptor-2 in patients with idiopathic dilated cardiomyopathy.

A peptide corresponding to the sequence 169-193 of the second extracellular loop of the human muscarinic acetylcholine receptor-2 was used as an antigen to screen sera from patients with idiopathic dilated cardiomyopathy (DCM, n = 36) and healthy blood donors (HBD, n = 40). The sera from 14 patients with DCM (38.8%) and 3 HBD (7.5%) recognized the muscarinic receptor peptide at dilutions varying from 1:20 to 1:160 in ELISA. A highly significant correlation (P = 0.006) was found between the presence of antimuscarinic receptor-2 autoantibodies and anti-beta-adrenoceptor-1 autoantibodies in the patients' sera. Affinity-purified autoantibodies from positive sera of patients with DCM recognized on the electrotransferred protein of rat ventricular membrane a major band of about 80 kD. Incubation of autoantibodies with membrane resulted not only in a decrease in the maximal binding sites (Bmax) but also in an increase in Kd of radioligand binding in a concentration-dependent manner. This suggests a mixed-type of inhibition. Moreover, preincubation with atropine abolished the inhibitory effect of autoantibodies on the receptor binding whereas carbachol appeared to have no effect on the activity of the autoantibodies. These data define a subgroup of patients with idiopathic DCM who have in their sera functionally active autoantibodies against muscarinic receptor-2.     

Chronic psychological stress seems associated with elements of the metabolic syndrome in patients with ischaemic heart disease

Background and objectives: Chronic psychological stress, the metabolic syndrome (MS) and ischaemic heart disease (IHD) seem closely connected. In this study, we evaluate the association between chronic stress and elements of MS in patients with stable IHD.

Design: Cross-sectional cohort study.

Methods: Three hundred and fifty patients with stable IHD were included. Chronic stress was evaluated by the two questionnaires, Major Depression Inventory (MDI) and the psychological wellbeing index WHO-5, as well as by Pressure Pain Sensitivity (PPS), a physiological measure of hyperalgesia at the sternum known to be associated to elements of the chronic stress syndrome. Elements of MS were evaluated by dual-energy X-ray absorptiometry, body weight, HOMA-IR and blood lipids.

Results: Depressive symptoms were associated with a high percentage of body fat (β?=?0.179, p?=?.001), and high level of triglycerides (β?=?0.150, p?=?.007). Low psychological wellbeing was associated with a high percentage of body fat (β?=?–0.165, p?=?.002) and low level of HDL cholesterol (β?=?0.128, p?=?.024). Chronic stress measured by PPS was associated with a high percentage body fat (β?=?0.327, p?<?.001), low body weight (β?=?–0.218, p?<?.001) and low HDL-cholesterol (β?=?–0.137, p?=?.013). Adjusting for several life style factors did not change these results.

Conclusions: In patients with stable IHD, different measures of chronic psychological stress seem associated with a high percentage of body fat and adverse blood lipids independent of several lifestyle factors.     

Chest pain in acute myocardial infarction: a descriptive study according to subjective assessment and morphine requirement

In 722 patients with suspected acute myocardial infarction (MI) we have tried to describe the course of chest pain according to their own assessment and morphine requirement. Patients were asked to score pain from 0-10 every second hour after arrival in the coronary care unit (CCU) and also to score their maximal pain at home. A very high intensity of chest pain was observed at home (mean score 7.1). At arrival in the CCU the mean pain score already had declined to 1.8, although 51% still had chest pain. Pain score declined successively during the first 12 hours in the CCU. At 24 hours after arrival, 20% still had some chest discomfort. In one quarter of the series a score of more than 0 was observed later than 24 hours after arrival in CCU. Patients developing definite MI had, as expected, a longer duration of pain and a much higher requirement of morphine compared with those with no MI. The difference between MI and no MI patients regarding subjective assessment of the initial intensity of pain at home and in hospital was, however, surprisingly low.