Epidemiology, clinical characteristics, outcome, morbidity and mortality in acromegaly based on the Spanish Acromegaly Registry (Registro Espanol de Acromegalia, REA)

OBJECTIVE: To undertake a multicentre epidemiological study reflecting acromegaly in Spain. DESIGN: Voluntary reporting of data on patients with acromegaly to an online database, by the managing physician. METHODS: Data on demographics, diagnosis, estimated date of initial symptoms and diagnosis, pituitary imaging, visual fields, GH and IGF-I concentrations (requested locally), medical, radiotherapy and neurosurgical treatments, morbidity and mortality were collected. RESULTS: Data were included for 1219 patients (60.8% women) with a mean age at diagnosis of 45 years (s.d. 14 years). Reporting was maximal in 1997 (2.1 cases per million inhabitants (c.p.m.) per year); prevalence was globally 36 c.p.m., but varied between 15.7 and 75.8 c.p.m. in different regions. Of 1196 pituitary tumours, most were macroadenomas (73%); 81% of these patients underwent surgery, 45% received radiotherapy and 65% were given medical treatment (somatostatin analogues in 68.3% and dopamine agonists in 31.4%). Cures (GH values (basal or after an oral glucose tolerance test) <2 ng/ml, normal IGF-I, or both) were observed in 40.3% after surgery and 28.2% after radiotherapy. Hypertension (39.1%), diabetes mellitus (37.6%), hypopituitarism (25.7%), goitre (22.4%), carpal tunnel syndrome (18.7%) and sleep apnoea (13.2%) were reported as most frequent morbidities; 6.8% of the patients had cancer (breast in 3.1% of the women and colon in 1.2% of the cohort). Fifty-six patients died at a mean age of 60 years (s.d. 14 years), most commonly of a cardiovascular cause (39.4%); mortality was greater in patients given radiotherapy (hazard ratio 2.29; 95% confidence interval 1.03 to 5.08; P=0.026), and in those in whom GH and IGF-I concentrations were never normal (P<0.001). CONCLUSIONS: This acromegaly registry offers a realistic overview of the epidemiological characteristics, treatment outcome and morbidity of acromegaly in Spain. As active disease and treatment with radiotherapy are associated with an increase in mortality, efforts to control the disease early are desirable.     

No association between histo-blood group antigens and susceptibility to clinical infections with genogroup II norovirus

Noroviruses (NoVs) are a leading cause of viral gastroenteritis in humans. In the present study, the association between NoV susceptibility and the ABO histo-blood group was studied during 2 outbreaks of acute gastroenteritis in military units in Israel caused by genogroup II (GII) NoVs. The findings demonstrate that, unlike for genogroup I of NoV, there is no association between the ABO histo-blood group and clinical infection with GII NoVs. This is the largest study to test the association between NoVs, proven clinical infection with GII, and the ABO histo-blood group.     

Patients at lower risk of arrhythmia recurrence: a subgroup in whom implantable defibrillators may not offer benefit. Antiarrhythmics Versus Implantable Defibrillator (AVID) Trial Investigators

OBJECTIVES: The goal of this study was to identify subgroups of arrhythmia patients who do not benefit from use of the implantable cardiac defibrillator (ICD). BACKGROUND: Treatment of serious ventricular arrhythmias has evolved toward more common use of the ICD. Since estimates of the cost per year of life saved by ICD therapy vary from $25,000 to perhaps $125,000, it is important to identify patient subgroups that do not benefit from the ICD. METHODS: Data for 491 ICD patients enrolled in the Antiarrhythmics Versus Implantable Defibrillators Study were used to create a hazards model relating baseline factors to time to first recurrent arrhythmia. The model was used to predict the hazard for recurrent arrhythmia among all trial patients. A priori cut points provided lower and higher recurrent arrhythmia risk strata. For each stratum the incremental years of life due to ICD versus antiarrhythmic drug therapy were calculated. RESULTS: Factors that predicted recurrent arrhythmia were: ventricular tachycardia as the index arrhythmia, history of cerebrovascular disease, lower left ventricular ejection fraction, a history of any tachyarrhythmia before the index event and the absence of revascularization after the index event. Survival times (over a follow-up of three years) were identical in each arm of the lowest risk sextile (survival advantage 0.03 +/- 0.12 [se] years), while the survival advantage for patients above the first sextile was 0.27 +/- 0.07 (se) years (two-sided p = 0.05). CONCLUSIONS: Patients presenting with an isolated episode of ventricular fibrillation in the absence of cerebrovascular disease or history of prior arrhythmia who have undergone revascularization or who have moderately preserved left ventricular function (left ventricular ejection fraction > 0.27) are not likely to benefit from ICD therapy compared with amiodarone therapy.     

Unilateral neck pulsations in a patient with a permanent pacemaker

An asymptomatic patient with a permanent pacemaker presented with unilateral accentuated neck pulsations. Evaluation revealed tricuspid insufficiency, a massively dilated right internal jugular vein, and obstruction of the left internal jugular vein. There was no evidence of aneurysm, vascular tumor, or fistula. The most likely explanation for this constellation of findings is tricuspid regurgitation occurring in the setting of unilateral internal jugular vein occlusion. Such a combination should be considered in the differential diagnosis of asymmetrical neck pulsations in a patient with a transvenous pacemaker.     

Effect of nitroglycerin during hemodynamic estimation of valve orifice in patients with mitral stenosis

In patients with mitral stenosis, valve orifice calculations using pulmonary capillary wedge pressure as a substitute for left atrial pressure may overestimate the severity of disease. Previous studies have shown that mitral valve area determined from transseptal left atrial pressure measurements exceeds that area derived from pulmonary wedge pressure measurements. This is probably due to pulmonary venoconstriction, which is reversed by nitroglycerin. Nitroglycerin, 0.4 mg, was administered sublingually to 20 patients with mitral valve disease during preoperative cardiac catheterization using the pulmonary capillary wedge pressure as the proximal hydraulic variable. At the time of a peak hypotensive effect, 3 to 5 minutes after nitroglycerin administration, the mean pulmonary capillary wedge pressure decreased from 23 +/- 2 (mean +/- SEM) to 19 +/- 2 mm Hg (p less than 0.005). The mean diastolic transmitral pressure gradient (12.6 +/- 1.2 mm Hg before and 11.5 +/- 1.0 mm Hg after nitroglycerin; p = NS) and cardiac output (4.0 +/- 0.3 to 4.1 +/- 0.3 liters/min; p = NS) did not change significantly. Nevertheless, the hemodynamic mitral orifice area, calculated using the Gorlin formula, increased from 0.8 +/- 0.1 to 1.1 +/- 0.2 cm2 (p less than 0.05). In 12 patients with isolated mitral stenosis, without regurgitation, the mitral valve orifice area after nitroglycerin was 0.4 +/- 0.2 cm2 larger than it was before drug administration (p less than 0.05). Administration of nitroglycerin during evaluation of mitral stenosis eliminates pulmonary venoconstriction, which raises the pulmonary capillary wedge pressure above the left atrial pressure in some patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reduced susceptibility to penicillin among pneumococci causing invasive infection in children - Canada, 1991 to 1998.

OBJECTIVE: To determine, over time, the rate and serotypes of pneumococci with reduced penicillin susceptibility obtained from children with invasive infection. DESIGN: Active, hospital-based, multicentre surveillance spanning from 1991 to 1998. SETTING: Eleven Canadian tertiary care paediatric facilities located from coast to coast. POPULATION STUDIED: 1847 children with invasive pneumococcal infection whose isolates (from a normally sterile site) were available for serotyping and standardized testing for penicillin susceptibility at the National Centre for Streptococcus. MAIN RESULTS: The prevalence of reduced penicillin susceptibility increased from 2.5% of 197 cases in 1991 to 13.0% of 276 cases in 1998. In the latter year, 8.7% of isolates had intermediate level resistance, and 4.3% had high level resistance. Since they were first detected in 1992, strains with high level resistance have been encountered only sporadically at most centres, but by 1998, all centres but two had encountered examples. Of 40 isolates with high level resistance and 101 isolates with intermediate level resistance, serotypes matched those included in new seven-valent conjugate vaccines for children in 97.5% and 79.2% of cases, respectively. CONCLUSIONS: Pneumococci with reduced susceptibility to penicillin are increasing in frequency across Canada among children with invasive infection. The Immunization Monitoring Program, Active data indicate that new conjugate vaccines could help to curb infections due to pneumococci with reduced susceptibility to penicillin but are unlikely to control completely the problem of antibiotic resistance.     

Multidisciplinary evidence-based medicine journal clubs: curriculum design and participants' reactions

BACKGROUND: Evidence-based medicine (EBM) is becoming an accepted educational paradigm in medical education at a variety of levels. It focuses on identifying the best evidence for medical decision making and applying that evidence to patient care. METHODS: Three EBM journal clubs were developed at the West Virginia University School of Medicine. One was for senior medical students, another for residents, and the third for primary care faculty members. In each, the sessions stressed answering clinical questions arising from actual patient-care issues. The curricular structure and development of the journal clubs are described. Participants anonymously evaluated aspects of the journal clubs regarding their educational value with Likert scale questions. RESULTS: Faculty members and residents generally gave high evaluations to all aspects of the EBM journal clubs. Student evaluations were more mixed. For each of the evaluation questions, the student means were lower than those of faculty and residents. However the differences reached statistical significance only in the responses to the usefulness of the sessions in understanding the medical literature (P < 0.01). Residents and faculty rated the EBM sessions more favorably than grand rounds or the resident lecture series. CONCLUSIONS: The establishment of evidence-based medicine journal clubs is feasible, and learners seem to value the sessions. More developed learners may gain more from the experience than those earlier in their medical education.     

Thromboembolism in nonvalvular atrial fibrillation: the answer may be in the ventricle.

Hypertensive emergencies, including hypertensive encephalopathy represents an acute threat to vital organ functions and call for urgent treatment. The intravenous medications currently available for the management of hypertensive emergencies, have significant potential for serious side effects and acute lowering of blood pressure has often been the cause of considerable morbidity and mortality. Nifedipine is known to be effective as an antihypertensive agent and it is widely used in hypertensive emergencies. We studied the efficacy and effective dose of nifedipine in 22 patients (9 females and 13 males; mean age 51) with hypertensive encephalopathy. Nifedipine (20 mg by oral drop) caused a significant fall in diastolic an systolic blood pressure in all patients from 236/121 to 172/96 mmHg after 30 minutes (P less than 0.005, P less than 0.001). Continuous therapy with nifedipine (2-5 mg every 2-3 hours, mean total dose 52 mg/24 h) gave successful control of blood pressure. These data prove that nifedipine can be used as the first-line drug for the treatment of hypertensive crises in patients with hypertensive encephalopathy.