Bolus i.v. nitroglycerin treatment of ischemic chest pain in the ED

A prospective case series was conducted to demonstrate the safety and efficacy of intravenous nitroglycerin (i.v. NTG) boluses in the treatment of ischemic chest pain (CP) in the emergency department (ED). Patients with CP symptomatic after sublingual nitroglycerin (SL NTG) therapy with a systolic blood pressure (SBP) greater than 95 mmHg were included. Patients were treated with i.v. NTG boluses of 0.05 mg to 0.4 mg during a 1- to 2-minute period per a protocol based on the patient's prebolus SBP. This was followed by a maintenance infusion. Additional NTG boluses were repeated every 5 minutes as needed. The end point of treatment was the resolution of chest discomfort, thrombolysis, or a SBP less than 95 mmHg. There were 16 cases of CP. All 16 patients treated, ie, 5 with acute myocardial infarction and 11 with unstable angina showed significant decrease in chest discomfort after 1 to 2 boluses. Two of five with acute myocardial infarction and 9 of 11 patients with unstable angina had complete relief of chest pain after 1 to 4 boluses. There were no episodes of hypotension (SBP < 90 mmHg) in any of the 16 cases. The judicious use of i.v. NTG boluses administered during a 1- to 2-minute period, in the ED, appears safe and efficacious in patients with CP unresponsive to SL NTG therapy.

Acute interstitial pneumonia in mink kits inoculated with defined isolates of Aleutian mink disease parvovirus

The present study addressed the causal role of Aleutian mink disease parvovirus (ADV) in acute interstitial pneumonia in mink kits. All the examined isolates of ADV caused interstitial pneumonia in newborn kits, although the severity of disease and the mortality varied. These findings indicate that ADV is the direct causal agent of this disease in mink kits and that cofactors, which could have been present in the original ADV-K isolate, do not play a role. Acute interstitial pneumonia characterized by hypertrophy and hyperplasia of alveolar type II cells, intranuclear viral inclusions, interstitial edema, and hyaline membrane formation was experimentally reproduced in mink kits infected as newborns with five different isolates of ADV. Four hundred forty-nine newborn mink kits were included in the study, of which 247 were necropsied. The lesions caused by the different isolates were indistinguishable by histopathologic examination, but the incidence (50-100%) and severity (mortality of 30-100%, n = 218) of disease among the mink kits varied. Also, the content of ADV antigens in the lungs of infected kits varied among the groups. According to these features, the examined isolates could be placed in groups of high and low virulence. ADV-K, ADV-Utah I, and ADV-DK were in a highly virulent group producing a mortality of 90-100% (n = 110) in mink inoculated as newborns. ADV-GL and ADV-Pullman belonged to a group of low virulence, with an incidence of clinical disease of 50-70% and a mortality of approximately 30-50% (n = 118) in kits inoculated as newborns. The mortality in the control group receiving a mock inoculum was around 12% (n = 34). The period from infection to development of fatal disease varied from approximately 12 days for the highly virulent isolates up to around 20 days for the isolates of low virulence. The 107 mink kits that survived inoculation with ADV as newborns developed lesions typical of classical Aleutian disease irrespective of the ADV isolate used. The lesions consisted of chronic immune complex-mediated glomerulonephritis and infiltrations with mononuclear cells, including plasma cells in lung, liver, spleen, kidney, mesenteric lymph node, and intestine. Surviving kits also had hypertrophy of the bronchus-associated lymphoid tissue and focal subpleural, intraalveolar accumulations of large cells with foamy cytoplasm, so-called lipid pneumonia.

Three-dimensional structure of a recombinant peroxidase from Coprinus cinereus at 2.6 A resolution

The structure of a recombinant peroxidase from the ink cap, Coprinus cinereus, CiP, is reported to 2.6 A resolution and refined to a R-value of 18.1%. The structure was solved by molecular replacement using the coordinates from a newly published ligninase structure. LiP. CiP crystallizes in space group P2(1)2(1)2(1) with two independent molecules in the asymmetric unit related by the vector 0.29b + 0.5c. The two CiP molecules are structurally identical; each contains two Ca2+ ions in positions equivalent to those found in the LiP structure. Two N-acetylglucosamines and one mannose residue were fitted into the density adjacent to two of the three predicted glycosylation sites. The refinement also included 40 and 41 water molecules, respectively, in the two CiP molecules. The structure of CiP displays a folding very similar to that of LiP. The active sites are almost identical in the LiP and CiP structures. CiP has a much larger opening to the active site than LiP.

The independent effects of exercise and estrogen on lipids and lipoproteins in postmenopausal women

OBJECTIVE

To assess the effects of a moderate exercise program with and without oral estrogen replacement on levels of lipids and lipoproteins in postmenopausal women.

METHODS

One hundred one postmenopausal women were randomized into four groups: control or sedentary (N = 20), exercise alone (N = 25), estrogen replacement using 0.625 mg conjugated equine estrogen (N = 28), and exercise supplemented with conjugated equine estrogen (N = 28). The exercise groups were placed on a moderate exercise program. Following baseline testing, each group returned at 3 and 6 months for cardiorespiratory fitness testing and serum lipid and lipoprotein profiles.

RESULTS

We found a significant decrease in systolic blood pressure (P < .05) in all treatment groups. The maximum oxygen uptake increased by 9.0 and 7.8% in the exercise and conjugated equine estrogen/exercise groups, respectively, compared to the other groups (P < .05). These responses were seen at both 3 and 6 months. Total exercise time (time spent on the treadmill until exhaustion during testing) significantly increased in the exercise group by 21% (P < .01). Exercise alone was associated with significant decreases in total cholesterol (5.2%, P < .05), triglycerides (2%, P < .05), and low-density lipoprotein (LDL) cholesterol (10%, P < .01), and a significant increase in the high-density lipoprotein (HDL) cholesterol-LDL ratio (17.2%, P < .01). Significant changes were noted in these values, as well as increases in HDL cholesterol (16 and 14.8%; P < .01) and apolipoprotein A1 (25.6 and 26.5%; P < .001) in the conjugated equine estrogen and conjugated equine estrogen/exercise groups, respectively. However, there were no differences in the changes observed in the conjugated equine estrogen groups with versus without exercise. No direct correlation was seen between measures of exercise performance and the changes seen in lipids and lipoproteins.

CONCLUSIONS

Estrogen therapy alone had the greatest beneficial effect on lipids and lipoproteins. Exercise alone resulted in a significant reduction in cholesterol, triglycerides, and LDL cholesterol, and an increase in the HDL-LDL ratio. However, combined conjugated equine estrogen and exercise did not demonstrate an added improvement in lipid metabolism. Physical fitness levels increased in the exercise groups, but not in the control group or the estrogen-alone treated women.

Acute kidney graft rejection. A morphological and immunohistological study on "zero-hour" and follow-up biopsies with special emphasis on cellular infiltrates and adhesion molecules

Serial biopsies from 41 consecutive renal allotransplanted patients were evaluated in order to obtain pretransplant data as well as information on well-functioning and acutely rejecting grafts. Each patient served as his own control. Thirty-five patients were followed according to the schedule which included biopsy prior to transplantation, shortly after opening of reanastomosis, at least once postoperatively (days 7-10), and furthermore whenever clinically indicated. The morphological evaluation was in each case combined with immunofluorescence (to detect immunoglobulins and complement fractions) and immunohistochemistry with a wide panel of monoclonal antibodies for T cells (CD2, CD3, CD4, CD8, gamma delta), B cells (CD20, CD22), macrophages (CD68, MAC387) NK cells (leu-7, CD16), activation markers (IL-2-R, Ki-67, transferrin-R), MHC antigens (HLA-ABC, HLA-DR), adhesion molecules (ICAM-1, VCAM-1, ELAM-1, PADGEM, VLA-4, LFA-1 alpha/beta), and growth factors (EGF, TGF-alpha, EGF-R). When 132 biopsies and 10 failed allografts were examined, no specific morphological or immunohistological parameter predictive of rejection or graft outcome could be found. Morphology in follow-up biopsies from non-rejecting and rejecting patients revealed a continuum of inflammatory changes, and several non-rejecting cases demonstrated cellular inflammatory infiltrates which could not be discriminated from those seen in acute rejection. Of the patients 44% had acute rejection accompanied by increased infiltration of T cells and macrophages showing enhanced IL-2-R expression, increased tubular and endothelial staining for MHC class II, ICAM-1, and VCAM-1, and strong leukocytic expression of VLA-4 and LFA-1 alpha/beta.

Sulfur- and Carbon-Bonded Forms of the Cobalt(III) Complex With the Ligands 2-Aminoethyl 3-Aminopropyl Sulfide and 1,1,1-Tris(aminomethyl)ethane

The new sulfur-bonded compound [Co(tame)( aeaps )] Cl3.H2O has been synthesized by the reaction of aeaps with Co(tame)Cl3 [tame = 1,1,1-tris( aminomethyl )ethane, and aeaps = 2- aminoethyl 3-aminopropyl sulfide or 3-thiahexane-1,6-diamine]. The Co(tame)( aeaps )3+ ion equilibrates in basic solution with the corresponding carbon-bonded species: Co(tame)( aeaps )3++HO-↔ Co(tame)(C-aeaps )2++H2O A salt of the carbon-bonded species, [Co(tame)(C- aeaps )](S2O6), has been isolated and its structure solved by X-ray diffraction analysis ( C- aeaps = 1,6-diamino-3-thiahexan-4-ide). The crystals are orthorhombic, Pna21, with cell dimensions a 20.455(10), b 9.960(10), c 8.982(10) Ǻ at 122(2) K. Preliminary thermodynamic and kinetic data are similar to the recently reported values for the corresponding coordination ion Co( tacn )( aeaps )3+ ( tacn = 1,4,7-triazacyclononane). In basic solution the Co(tame)( aeaps )3+ species exchanges one of its methylene protons orders of magnitude faster than any other methylene protons and also much faster than it forms the alkyl complex as shown by 13C n.m.r. measurements.

Therapeutic effect of loratadine on pruritus in patients with atopic dermatitis. A multi-crossover-designed study

The aim of the study was to assess the therapeutic efficacy of loratadine on pruritus in patients with atopic dermatitis, considering the patients' sensation of itch. Sixteen patients, mean age 24.8 years, with moderate or severe atopic dermatitis were included in a double-blind and placebo-controlled study with a six-period, multi-crossover design. The patients were given 10 mg loratadine or placebo every day, alternating between loratadine and placebo every 2 weeks. The degree of pruritus during the day and during the night was recorded by the patients every morning and every evening, respectively, on a 10-cm visual analog scale. The study detected a significant effect of loratadine, as compared with placebo, on pruritus during the day, pruritus during the night, and severity of rash. At least nine of the 16 patients included were classified as responders and only one as a nonresponder to loratadine treatment. It is concluded that loratadine may be tried as an adjuvant therapy in the management of severe and moderate atopic dermatitis, in patients complaining of pruritus.

Decreased serum insulin-like growth factor I during puberty in children with insulin dependent diabetes mellitus (IDDM)

Previous reports concerning insulin-like growth factor-I (IGF-I) in diabetics are conflicting. This study describes IGF-I in children with insulin-dependent diabetes mellitus (IDDM) and healthy controls in relation to pubertal development. Sixty-six children participated (34 girls and 32 boys) of which 33 had IDDM. The mean age in the study population was 14.3 years, (range 7.1 to 19.7). Serum IGF-I was significantly decreased in diabetics. Diabetic girls had a mean IGF-I of 28.3 (14.4; = SD) nmol/l compared with 42.8 (15.0) nmol/l in controls. In diabetic boys the result was 30.0 (16.0) nmol/l compared with 44.1 (23.4) in controls. Growth hormone was measured in only one fasting morning serum sample from each individual. There was no difference between girls, but diabetic boys had higher mean serum concentration of growth hormone than controls (3.5 (4.8) vs. 1.8 (1.5) micrograms/l respectively). Diabetic girls had delayed menarche, corresponding to a slightly delayed bone maturation.

Sulphatide antigen in islets of Langerhans and in diabetic glomeruli, and anti-sulphatide antibodies in type 1 diabetes mellitus

Clinical coincidence between diabetes and neurological disorders, and sharing of antigen determinants between islets of Langerhans and neural tissue, has been suggested. Sulphatide is a neural epitope which can be visualized with a monoclonal antibody Sulph I. Different tissues were examined by immunohistological methods. Sulphatide and anti-sulphatide antibodies were determined by thin-layer chromatographic techniques. IgG was isolated using protein A columns. A specific staining by Sulph I was found of rat islets, assigned to the secretory granules of both alpha and beta cells. No labelling of the exocrine tissue or other body tissues was seen, except for nerve and kidney structures. The latter showed staining of the distal tubules and, in addition, but only in the diabetic kidney, of glomeruli located in the subendothelial area in the capillary loops and the mesangial space. Sera from 38% of 40 spontaneously diabetic BB rats displayed anti-sulphatide antibodies, mainly IgG, whereas all 30 control Lewis rats were negative. Most recently we have demonstrated anti-sulphatide antibodies in 88% of 57 patients with newly diagnosed Type 1 diabetes (titres of > 1:400); all 135 healthy control persons were negative. The sulphatide antibody reactivity was present in the IgG fractions of the patients' sera. Thus, sulphatide is demonstrated in islets of Langerhans and in kidney related to the diabetic lesion, and, furthermore, anti-sulphatide antibodies exist in Type 1 diabetes mellitus.

Safety of enoxaparin and dextran-70 in the prevention of venous thromboembolism in digestive surgery. A play-the-winner-designed study

A total of 327 patients were included in a play-the-winner (PTW)-designed study comparing the safety of prophylaxis with enoxaparin and dextran-70 in patients undergoing digestive surgery. In a PTW-designed study the treatment of any next patient will depend on the outcome of the previous one. If successful, the next patient will receive the same treatment. Excessive bleeding, on the basis of specified criteria, severe adverse effects, or occurrence of clinically detected venous thromboembolism was classified as failure. The PTW design allocates most patients to the superior treatment. In this study 200 patients were given enoxaparin and 127 dextran-70. The success rate was 83% in the enoxaparin group and 74.8% in the dextran-70 group (p = 0.05). The survival analysis of 'Number of patients before change in treatment' shows a significant difference in favour of enoxaparin (p = 0.05). Enoxaparin seems to be superior to dextran-70 as a prophylaxis in digestive surgery. The PTW model is a suitable design in such studies.

Crystallization and X-ray diffraction analysis of recombinant Coprinus cinereus peroxidase

Crystals suitable for an X-ray diffraction investigation have been obtained of recombinant Coprinus cinereus peroxidase expressed in Aspergillus oryzae. The crystals were grown by the hanging drop method with polyethylene glycol 6000 as the precipitant. A pH range from 6.2 to 8.0 and CaCl2 or MgCl2 present at a concentration of 0.35 M were essential for the crystal growth. A metastable monoclinic modification can be obtained under certain conditions, and with variations in temperature they are transformed into a stable orthorhombic modification. With CaCl2 as the additive, the unit cell dimensions were a = 74.9 A, b = 76.8 A and c = 128.2 A. With two peroxidase molecules per asymmetric unit, the solvent content is 49% (v/v). In the diffraction pattern, the reflections Okl are systematically very weak for k = 2n + 1. Combined with an analysis of the Patterson function, this showed that the two independent molecules are related by the pseudotranslational symmetry 0.29a + 0.5b. The possible space groups are P2(1)2(1)2(1) or P2(1)22(1) because of this pseudosymmetry. The crystals diffract to a resolution of 2.9 A.

Loratadine and terfenadine in perennial allergic rhinitis. Treatment of nonresponders to the one drug with the other drug

The efficacy of loratadine and terfenadine in perennial allergic rhinitis was evaluated in a double-blind, selected cross-over study consisting of two phases. During the first phase, 76 patients with perennial allergic rhinitis, 8-67 years old, were included in the study. Of these, 41 patients received loratadine 10 mg daily, and 35 patients received terfenadine 60 mg twice daily, for 2 weeks. According to symptoms and side-effects, 32 patients were classified as responders to loratadine, and 28 patients as responders to terfenadine. All observed symptoms were significantly reduced in both treatment groups, but with no significant differences between the two groups. Side-effects were few and mild. In patients with normal IgE, loratadine was significantly superior to terfenadine in relieving nasal secretion, whereas terfenadine was significantly superior to loratadine in relieving nasal congestion. In patients with increased IgE, patients treated with loratadine showed significantly greater reduction in sneezing than patients treated with terfenadine. A positive correlation between total IgE and reduction in overall symptoms was found for patients treated with loratadine, whereas a negative correlation was found for patients treated with terfenadine. During the second study phase, the nonresponders received the other drug for 2 weeks. All seven nonresponders to terfenadine responded to loratadine after crossing over, whereas four of nine nonresponders to loratadine responded to terfenadine. Nonresponders to one drug may respond to the other drug. Thus, more than one antihistamine drug should be tried in perennial allergic rhinitis if the first fails.

Ketoprofen controlled release (CR) in the treatment of osteoarthrosis; a double blind, randomized multicentre study of single morning versus evening dose. Norwegian Study Group of General Practitioners

OBJECTIVE

To compare the morning and evening dose of 200 mg ketoprofen controlled release formulation with regard to both efficacy and GI tolerability.

DESIGN

Double-blind, randomized multicentre prospective trial with cross-over design combined with a parallel design.

PARTICIPANTS

One hundred and eight female and 55 male patients with osteoarthrosis in hip(s) or knee(s) necessitating treatment with nonsteroidal antiinflammatory drugs.

MAIN OUTCOME MEASURE

The degrees of pain and stiffness and joint movement ability in joints with osteoarthrosis.

RESULTS

Both the morning and the evening dose demonstrated a significant effect (p < 0.01) on all efficacy variables. The reduction in degree of pain in the afternoon and in the evening was significantly higher (p < 0.01) for the morning dose. The total frequency and degree of gastrointestinal discomfort increased significantly (p < 0.01) during both treatment periods. The increases were mainly caused by increased gastric pain and constipation. No significant differences were found between the two regimes regarding tolerability.

CONCLUSION

Ketoprofen controlled release given once daily in the morning compared to the evening to patients with osteoarthrosis may increase the efficacy without reducing the tolerability of the drug.

Clinical and serologic evaluation of neonates for congenital syphilis: a continuing diagnostic dilemma

Neonates born to women with reactive serologic tests for syphilis were studied; the total of 116 included 18 who were symptomatic, 60 asymptomatic but possibly infected, and 38 asymptomatic and probably uninfected. The fluorescent treponemal antibody-absorption (FTA-ABS) 19S IgM test and an IgM capture ELISA for Treponema pallidum, both treponema-specific assays, and the reverse enzyme-linked immunospot (RELISPOT), which detects immunoglobulin-secreting cells and is a nonspecific indicator of infection, were evaluated. Sensitivities among symptomatic neonates were 88% (IgM ELISA), 73% (FTA-ABS), and 78% (RELISPOT). Specificities ranged from 97% to 100%. A major problem has been the inability to identify which asymptomatic but possibly infected neonate is really uninfected. Among 41 such babies who had all three tests done, 93% were negative by all assays, suggesting they were uninfected or recently infected. Strategies to accurately identify the truly uninfected asymptomatic newborn would prevent the unnecessary hospitalization of all at-risk infants, resulting in improved quality of care and reduced costs.

The origin of alcohol-related social norms in the Saami minority

The present paper addressed the problem of the origin of alcohol-related social norms in the Saami minority in northern Norway. Based on data from studies of comparable ethnic minorities in Greenland, North America and Australia it could be expected that alcohol use- and abuse would be more prevalent in the Saami than in the Norwegian populations of northern Norway. No data to support this hypothesis exist. On the contrary, available data suggest that drinking problems in this group are similar to those of the majority in the area. The present paper developed the hypothesis that Saami alcohol-related social norms originated in the Laestadian religious revival. The paper investigated the impact of the Laestadian culture in the formation of alcohol-related social norms. It was concluded that the Laestadian sobriety norm, and the norm of abstinence from the use of adiafora, have influenced alcohol-related behaviour in the Saami group in such a way that this group does not conform to the drinking behaviour found in comparable minorities.

Diabetes mellitus secondary to chronic pancreatitis

From the present review it appears that insulin-dependent diabetes is a common finding in chronic pancreatitis, and impaired secretion of insulin from beta-cells of the pancreatic islets is essential for the development of this form of secondary diabetes. Judged from a positive correlation between insulin secretory capacity and stimulated pancreatic enzyme output, beta-cell function may decrease in parallel with exocrine pancreatic function. However, in patients with insulin-dependent diabetes secondary to chronic pancreatitis beta-cell function was preserved to a greater extent and glucoregulation was better than in comparable Type 1 (insulin-dependent) diabetic patients. Immunological phenomena and associations with certain HLA-alleles characterizing Type 1 diabetes mellitus were not found in insulin-dependent diabetes secondary to chronic pancreatitis. This may contribute to the slower destruction of the beta-cells in chronic pancreatitis than encountered in Type 1 diabetes. The small number of chronic pancreatitis patients who developed totally absence of endogenous insulin production still have some alpha-cell function during i.v. arginine and meal stimulation. However, insulin-induced hypoglycemia and insulin withdrawal did not stimulate glucagon secretion in the secondary diabetic patients in contrast to comparable Type 1 diabetics. Nevertheless, blood glucose counterregulation is intact in the secondary diabetics due to preserved catecholamine secretion. Furthermore, ketonemia develops during dissipation of insulin, in spite of absence of increased glucagon secretion, emphasizing the role of insulin dissipation for the development of ketoacidosis in this form of diabetes. The suggested increased susceptibility to severe hypoglycemia and less tendency to development of ketonemia may further be influenced by altered insulin sensitivity, nutritional factors and concomitant hepatic failure in diabetes secondary to chronic pancreatitis. Pancreatic polypeptide secretion was absent in chronic pancreatitis without endogenous insulin production. Pancreatic polypeptide secreting cells thus seem to be at least as vulnerable as the beta-cells to the destructive processes characterizing chronic pancreatitis, whereas glucagon secreting alpha-cells preserve secretory capacity to a greater extent than PP-cells and beta-cells. No data, however, favour the view that absent pancreatic polypeptide secretion has any major effect on the glucoregulation in diabetes secondary to chronic pancreatitis. Increased plasma concentration of somatostatin was found in patients with insulin-dependent diabetes secondary to chronic pancreatitis. The source of somatostatin in the patients is unknown, but somatostatin may contribute to a reduction in overall blood glucose level in patients without endogenous insulin secretion due to inhibition of glucagon secretion.(ABSTRACT TRUNCATED AT 400 WORDS)

[Smoking habits and risk of coronary heart disease, especially risk associated with low daily tobacco consumption]

The purpose of this study was to estimate the risk of acute myocardial infarction related to smoking habits, especially the risk among smokers with a daily tobacco consumption of five grams or less. The study is based on data from the 1914 population examined by the Glostrup Population Studies at the age of 50 and 60 in 1964 and 1974. Information concerning deaths and cases of hospitalisation has been obtained from national registers up to 1985. Blood pressure, lipids, body mass index and physical activity were used as confounders. It was not possible to make a definite conclusion for the group smoking five grams or less daily as a class, since both the size of the group and the number of myocardial infarctions within it were small. When tobacco consumption was used as a quantitative variable the risk of myocardial infarction was found to increase with increasing amount but the relation was found not to be non-linear. The best description of the tobacco-related risk of myocardial infarction was a logarithmically relation to daily tobacco consumption.