A proposal for the clinical use of flecainide

Effective antiarrhythmic therapy requires a carefully considered approach, including an understanding of the arrhythmia, the underlying cardiac disease and the drug's pharmacokinetics. Flecainide is a new antiarrhythmic drug that may soon be released for general use. Flecainide demonstrates unsurpassed efficacy in chronic ventricular arrhythmias in stable patients and may become a first-choice drug because of its ease of administration, efficacy and favorable tolerance. Twice-daily dosing with 100 to 200 mg usually provides effective therapy. Clinical experience suggests flecainide to be indicated in the treatment of uniform and multiform ventricular premature complexes, coupled ventricular premature complexes, and episodes of nonsustained ventricular tachycardia. A lower response rate is observed in preventing induction of sustained ventricular tachycardia, and these patients should be carefully selected. Flecainide is promising in the treatment of supraventricular tachycardias using atrioventricular nodal or extranodal reentrant pathways, although this use is still investigational in the United States. The drug's use for arrhythmias during acute myocardial infarction requires further study. Flecainide possesses modest negative inotropic potential. Proarrhythmic or other adverse reactions have occurred primarily in settings of high drug level, poor ventricular function or refractory, malignant arrhythmias, suggesting caution in these groups.     

Computed tomography in the evaluation of abdominal abscesses

Review of experience using computed tomography in 50 patients with a suspected diagnosis of abscess indicated it to be accurate and reliable. Most abscesses were sharply demarcated masses. After intravenous injection of contrast medium, the rim was enhanced in about 35 percent of the patients. In six patients the inflammatory mass had ill-defined borders. It is concluded that when the computed tomographic findings are correlated with clinical history, the correct diagnosis can almost always be reached. If surgery is not contemplated, computed tomography or ultrasound-guided needle aspiration should be performed to confirm the diagnosis.     

Prevention of extensor lag after indicis proprius tendon transfer.

An experiment on fresh cadaver hands showed that a longitudinal incision of the hood did not affect index extension when traction was made on the common extensor tendon, but that excision of a portion of the hood containing the indicis proprius caused an extensor lag. The lag was eliminated by repair of the hood, providing that the closure was not too tight to prevent normal excursion of the hood. These findings were correlated with findings in patients who had undergone indicis proprius tendon transfer. Extensor lag after indicis proprius transfer is not caused by removal of the force of the tendon per se, but by factors which cause either disruption of normal hood function or tethering of its normal excursion.     

Jaundice in patients with acute cholecystitis: Its validity as an indication for common bile duct exploration

Our study demonstrates that (1) mild to moderate jaundice is frequently seen in patients with acute cholecystitis; (2) severe degrees of jaundice were seen in two patients without the presence of common duct stone or recognizable obstruction of the common bile duct; (3) only one of forty-one patients with acute cholecystitis had common bile duct stone; (4) jaundice does not appear to be a compelling reason for choledochotomy; and (5) less invasive technics such as intravenous and intraoperative cholangiography should suffice to exclude the possibility of common bile duct stone in patients with acute cholecystitis.     

Experience with electrophysiologically guided therapy of ventricular tachycardia with flecainide: summary of long-term follow-up

In a heterogeneous group of 15 patients with clinical syncope or documented sustained ventricular tachycardia (VT), with induced sustained or nonsustained VT at programmed electrical stimulation, flecainide prevented tachycardia induction in 9 of 15 patients (60%) and improved responses in 2, for a 73% initial favorable response rate. Cycle length of induced rhythms increased an average of 141 ms after the drug. Antiarrhythmic response rate was higher in the absence of coronary artery disease. Ten of these patients were selected for a long-term drug trial. After a median follow-up of 13.5 months, 8 patients (53%) continue to receive flecainide, 6 (40%) successfully treated with flecainide alone and 1 each treated with concomitant therapy with amiodarone and a programmable antitachycardia pacemaker. Minor dosage adjustments were made during early outpatient therapy in 5 patients. Those continuing on therapy show a remarkable absence of side effects and stable drug concentrations. Therapy failed in 2 patients at 0.5 and 4 months, in 1 in association with progression of cardiomyopathy and in another with recurrence of sustained (slow) VT. Although our results have been favorable, preliminary reports from other laboratories have been mixed. Therefore, further experience is needed. In summary, flecainide appears promising in selected patients with VT using a carefully monitored approach including electrophysiologic induction studies.     

A Demographic Study of the Practice of Ophthalmololgy in the State of Utah

A demographic survey of the practice of ophthalmology in the State of Utah has disclosed that there has been tremendous increase in the number of practicing ophthalmologists, particularly in the last 8 years. This increase has severely decreased the number of surgeries performed per ophthalmologist in the state, with notable regional differences.     

Pirmenol for control of ventricular arrhythmias: oral dose-ranging and short-term maintenance study

The antiarrhythmic efficacy and safety of oral pirmenol hydrochloride were assessed during a controlled, dose-ranging and short-term maintenance study in 12 patients with frequent (greater than 480/8 hours) premature ventricular complexes (PVCs). Eleven patients (92%) responded favorably (greater than 70% PVC suppression) to a trial of different doses. Mean interval (8-hour) suppression of PVC frequency was 95% in these 11 and 86% in the entire group. Twenty-four-hour suppression was similar in responders (88%). Repetitive PVCs were essentially eliminated. The mean effective dose was 316 mg/day (105 mg/8 hours). The average predose (trough) plasma concentration at the end of dose ranging was 1.4 micrograms/ml and the drug elimination half-life 7.3 hours (n = 12). Of 11 responding patients, 10 completed a 2-week outpatient trial. Pirmenol continued to be effective and tolerated in 8 patients, maintaining an overall average outpatient PVC suppression of 80%. The electrocardiographic intervals were mildly prolonged after multiple dosing (PR + 7%, QRS + 12%, QTc + 8%; all p less than 0.01). Blood pressure and heart rate did not change during treatment. The echocardiographic ejection fraction was maintained. Thus, oral pirmenol appears to be effective, conveniently administered and well tolerated as an antiarrhythmic agent for control of ventricular extrasystoles.     

Medical education in China: Historical background,present status,and further development

Sixty-five abscesses, including 6 infected biliary systems and 15 sterile fluid collections, were treated by percutaneous catheter drainage in 77 febrile patients who were evaluated by computerized tomograhy or ultrasonography for intraabdominal infection. Percutaneous catheter drainage and systemic antibiotic administration without surgery provided satisfactory control of infection in 52 of 65 abscesses (80 percent). Catheter drainage followed by surgical exploration for abscess control was performed in an additional 5 of the 65 abscesses (7 percent). Nine deaths (14 percent) occurred in the abscess group of 64 patients. In 15 patients, aspirations, Gram stain, and culture of the abnormal fluid collection revealed sterile fluid. Drainage with a single catheter allowed complete resolution in 14 of 15 sterile collections. Surgery was performed electively in one patient with a fistula from a pancreatic pseudocyst in the small bowel. No deaths occurred in the noninfected group of 15 patients, 2 of whom underwent drainage of coexisting abscesses.