Post-discharge survival following pre-hospital cardiopulmonary arrest due to cardiac aetiology: temporal trends and impact of changes in clinical management.

AIMS: To determine whether survival after discharge following pre-hospital cardiopulmonary arrest has improved. METHODS AND RESULTS: The Heartstart Register was used to identify all 1659 patients discharged alive from Scottish hospitals during 1991-01 following pre-hospital arrest due to cardiac aetiology. The cohort was split into tertiles using year of arrest. A Cox proportional hazards model was used to determine risk of death relative to 1991-93. Patients who survived cardiopulmonary arrest in 1997-01 were less likely to die from any cause (unadjusted HR 0.60, 95% CI 0.48-0.75, P<0.001) or cardiac disease (unadjusted HR 0.50, 95% CI 0.38-0.65, P<0.001). After adjustment for case-mix, there remained significant declines in all-cause (adjusted HR 0.62, 95% CI 0.50-0.78, P<0.001) and cardiac death (adjusted HR 0.52, 95% CI 0.39-0.68, P<0.001). Clinical management had improved, with increased use of thrombolysis (47-63%, chi2 trend, P<0.001), beta-blockers (28-53%, chi2 trend, P<0.001), ACE-inhibitors (48-69%, chi2 trend, P<0.001), and anti-thrombotics (79-88%, chi2 trend, P<001). Adjustment for recorded changes in management attenuated the decline in all-cause death (adjusted HR 0.77, 95% CI 0.60-0.98, P=0.03). CONCLUSION: Survival following cardiopulmonary arrest has improved after adjusting for changes in case-mix. Better clinical management has contributed to this improvement.     

Distribution of cystatin C (gamma-trace), an inhibitor of lysosomal cysteine proteinases, in the anterior lobe of simian and human pituitary glands

Cystatin C, a protein inhibitor of lysosomal cysteine proteinases, was demonstrated by immunohistochemical techniques to be present in most luteinizing hormone- (LH-)containing cells in simian and human adenohypophyses. Immunoreactivity of cystatin C was also found in simian adrenocorticotrophic hormone- (ACTH-)containing cells localized to an area corresponding to the pars intermedia but not in the ACTH-containing cells of the anterior pituitary lobe of monkey. No immunoreactivity of cystatin C was detected in the growth hormone- (GH-) and prolactin-containing cells of monkey and man.     

缺血性卒中患者的早期处理指南--美国卒中学会卒中委员会科学声明

1994年,美国心脏学会(AHA)卒中委员会委托一个专门研究小组撰写了急性缺血性卒中患者的处理指南。1996年,在静脉rtPA治疗急性缺血性卒中得到食品与药物管理局(FDA)批准后,这项指南又补充了一系列的推荐。自早先的指南发表以来,又有几种有前途的急性缺血性卒中治疗的干预方法先后经过了临床试验的评价,急性处理的其他组成部分也进行了进一步的评估,所有这些新的资料都促进了这一新版指南的出现。     

Termination of sustained ventricular tachycardia by external noninvasive pacing

Cardiac pacing has proven useful in the termination of sustained ventricular tachycardia (VT). In this study, the effectiveness of external noninvasive temporary pacing was compared with traditional endocardial burst ventricular pacing for the termination of sustained and hemodynamically stable VT. In 14 patients, 16 VT morphologies induced by programmed right ventricular extrastimulation were reproducibly terminated by endocardial burst pacing (3 to 9 complexes). VT cycle lengths averaged 392 +/- 97 ms (standard deviation) and ranged from 300 to 690 ms. The endocardial burst pacing cycle length used to terminate VT averaged 298 +/- 93 ms (range 220 to 600 ms). External burst pacing terminated 14 of 16 VT morphologies (88%). The pacing cycle length used to terminate these 14 VTs averaged 282 +/- 44 ms. The number of ventricular captures ranged from 5 to 20 beats. Failure to terminate 2 VT morphologies probably represented a failure of the device to capture the ventricle. Acceleration of VT occurred in 1 patient with burst external noninvasive pacing. These observations suggest that external burst pacing may be an effective means of terminating sustained VT in some patients.     

Overcoming the blood-brain barrier with high-dose enzyme replacement therapy in murine mucopolysaccharidosis VII

Enzyme replacement therapy (ERT) effectively reverses storage in several lysosomal storage diseases. However, improvement in brain is limited by the blood-brain barrier except in the newborn period. In this study, we asked whether this barrier could be overcome by higher doses of enzyme than are used in conventional trials. We measured the distribution of recombinant human beta-glucuronidase (hGUS) and reduction in storage by weekly doses of 0.3-40 mg/kg administered i.v. over 1-13 weeks to mucopolysaccharidosis type VII mice immunotolerant to recombinant hGUS. Mice given up to 5 mg/kg enzyme weekly over 3 weeks had moderate reduction in meningeal storage but no change in neo-cortical neurons. Mice given 20-40 mg/kg three times over 1 week showed no reduction in storage in any area of the CNS except the meninges. In contrast, mice receiving 4 mg/kg per week for 13 weeks showed clearance not only in meninges but also in parietal neocortical and hippocampal neurons and glia. Mice given 20 mg/kg once weekly for 4 weeks also had decreased neuronal, glial, and meningeal storage and averaged 2.5% of wild-type hGUS activity in brain. These results indicate that therapeutic enzyme can be delivered across the blood-brain barrier in the adult mucopolysaccharidosis type VII mouse if administered at higher doses than are used in conventional ERT trials and if the larger dose of enzyme is administered over a sufficient period. These results may have important implications for ERT for lysosomal storage diseases with CNS involvement.     

Failure of doxycycline treatment in aquarium-associated Mycobacterium marinum infections

Two cases of aquarium-associated Mycobacterium marinum infections are described. Neither was cured by the initial therapy consisting of surgical excision followed by doxycycline treatment. Both strains of M. marinum were shown to be resistant to doxycycline. In one patient the lesions were subsequently healed with cotrimoxazole. The other patient, a 12-year-old girl with sporotrichoid spread of the lesions on the lower arm, failed to respond satisfactorily to a combination of rifampicin and ethambutol despite favourable effect in vitro of both drugs. Nine months after the initial treatment, the infection was finally cured with renewed surgery followed by additional chemotherapy with rifampicin and ethambutol. No signs of immunological disorder could be detected in the patient. Increased awareness of the possibility of tetracycline resistance of M. marinum is advocated. A combination of adequate chemotherapy and surgical intervention may be required at least in complicated cases.     

Syncope as an initial manifestation of atypical lipomatous hypertrophy of the interatrial septum

Lipomatous hypertrophy of the interatrial septum (LHIS) is an incidental echocardiographic abnormality characterized by dumb-bell configuration of the interatrial septum from excess fat deposition. We report a case of syncope in a patient with LHIS obstructing the superior vena cava at the right atrial junction.     

Piggy-back pacing: implantation of pacemaker and defibrillator on top of each other.

Following the publication of several landmark trials, there has been a significant increase in the cardiac device implantation. Within this population there are a number of patients who have pre-existing cardiac devices that have been placed for a number of different conditions. While the usual approach is to remove the existing unit and replace it with a new device with the removal or capping of existing lead systems, this practice often sacrifices an existing unit that still possesses good battery longevity. We explored the possibility of separating the pacing and defibrillating functions by implanting a new device on the top of the old device in a 'piggy-back fashion'. We report a series of four cases (with various indications) with differing combinations of devices. The procedure was performed safely in every one of them, and no device-device interaction was noted. Combining the new with existing units in a 'piggy-back' manner may be a safe and cost-effective technique in the selected cases.