Abnormalities in exercising skeletal muscle in congestive heart failure can be explained in terms of decreased mitochondrial ATP synthesis, reduced metabolic efficiency, and increased glycogenolysis

OBJECTIVE

To distinguish between the effects of reduced oxidative capacity and reduced metabolic efficiency on skeletal muscle bioenergetics during exercise in patients with congestive heart failure.

DESIGN AND PATIENTS

Patients were studied by 31P magnetic resonance spectroscopy during aerobic exercise and recovery, and results compared with controls.

RESULTS

In flexor digitorum superficialis muscle (26 patients) there was a 30% decrease in oxidative capacity compared with control (mean (SE) 36 (2) v 51 (4) mM/min) and also a 40% decrease in "effective muscle mass" (5 (1) v 9 (1) arbitrary units), probably at least partly the result of reduced metabolic efficiency. Both contribute to increased phosphocreatine depletion and intracellular acidosis during exercise. However, an increased concentration of ADP (an important mitochondrial regulator) during exercise permitted near-normal rates of oxidative ATP synthesis. Results were similar in gastrocnemius muscle (20 patients), with a 30% decrease in maximum oxidative capacity (29 (4) v 39 (3) mM/min) and a 65% decrease in effective muscle mass (5 (1) v 13 (2) arbitrary units). Exercise training improved maximum oxidative capacity in both muscles, and in gastrocnemius effective muscle mass also.

CONCLUSIONS

Skeletal muscle exercise abnormalities in patients with congestive heart failure results more from decreased metabolic efficiency than from the abnormalities in mitochondrial oxidation. Both decreased efficiency and defective mitochondrial oxidation result in an increased activation of glycogen phosphorylase, and may be improved by exercise training.

Status, communality, and agency: implications for stereotypes of gender and other groups

Four studies addressed the hypothesis, based on correspondence bias, that low- relative to high-status individuals are perceived as more communal and less agentic. Study 1 instantiated status in terms of occupations, and findings were as expected. The findings of Study 2 reconciled those of Study 1 and of A.H. Eagly and V.J. Steffen (1984) in that they demonstrated that high-status occupations are differentially construed in terms of their interpersonal communal demands. The hypothesis received clear support in Studies 3 and 4, in which a general instantiation of status independent of occupations, social roles, and gender was adopted. The findings are discussed in terms of gender stereotypes and social role theory of gender (A.H. Eagly, 1987) as well as in terms of other stereotypes.

A corporate needs assessment for the purchase of district nursing: a qualitative approach

A qualitative research methodology was applied to a corporate assessment of need for district nursing services. Semi-structured interviews were held with district nurses and the transcripts analysed for common themes. The major determinants of district nurses' roles were the priorities and practices of other community-based services, particularly social services and primary care. Purchasing and contract setting in this area needs to focus more on the interface with other services.

Bernhard Clinic meeting need in lesbian sexual health care

Whether or not suggestions that one in 10 women are lesbian, the lack of specialist clinics to deal with this group's sexual health care was not obvious when the Bernhard Clinic was set-up two years ago. This article shows that the immediate response was confirmation enough that there is a dire need for more clinics of this type.

Nasal polyps: effects of seasonal allergen exposure

Nasal polyps are characterized by chronic eosinophilic inflammation and often coexist with rhinitis and asthma. Many patients with polyps have no detectable allergy, and it is considered that allergy, at least in many cases, is not relevant to polyp to pathogenesis. To explore the association of nasal polyps with allergy, 16 patients with polyps and ragweed allergy (PRW +) and 16 patients with polyps who were not allergic to ragweed (PRW-) were compared with patients without polyps, 16 who were allergic to ragweed (NPRW +) and 16 who were not allergic to ragweed (NPRW-), before and during the ragweed season. The level of ragweed allergy was comparable in the PRW+ and NPRW+ populations as determined by ragweed skin test wheal diameter, ragweed IgE RAST percent binding, and total serum IgE. Symptom scores before the ragweed season recorded on visual analog scales for the symptoms of blockage, sneezing, decreased smell, itch, postnatal drip, and runny nose were high in patients in the PRW+ and PRW- groups and did not change during ragweed season. Mean symptom scores were low in the NPRW+ group before ragweed season and increased during the season to levels similar to those of patients in the PRW+ and PRW- groups. Preseason nasal lavage albumin concentration was higher in subjects with polyps than those without polyps (58.5, 98) versus (13.6, 15 micrograms/ml) (p = 0.02) and did not change significantly in any group with seasonal exposure. Data are presented as mean, 1 SD; comparisons are made with unpaired t tests.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic effects of captopril and isosorbide mononitrate started early in acute myocardial infarction: a randomized placebo-controlled study

OBJECTIVES

The aim of this study was to study the hemodynamic effects of orally administered captopril and isosorbide mononitrate in suspected acute myocardial infarction.

BACKGROUND

Early treatment with converting enzyme inhibitors and nitrates in acute myocardial infarction may limit infarct expansion and prevent left ventricular dilation.

METHODS

In a double-blind study, 81 patients were randomized within 36 h of the onset of symptoms of suspected acute myocardial infarction to 1 month of oral captopril (6.25 mg initial dose, followed 2 h later by 12.5 mg and continuing with 12.5 mg three times daily), isosorbide mononitrate (initial dose 20 mg followed by 20 mg three times daily) or matching placebo. The effects of treatment on changes from baseline in mean arterial blood pressure, heart rate, stroke volume, cardiac output and systemic vascular resistance were assessed noninvasively using Doppler echocardiography 1 h after the first dose, 1 week after infarction and at 6 weeks (that is, 2 weeks after the scheduled end of trial treatment).

RESULTS

One hour after the start of treatment, blood pressure was reduced by approximately 10% with both captopril and isosorbide mononitrate, but this difference did not persist at 1 week. Captopril was associated with a significant increase in cardiac output compared with placebo of 13 +/- 3% at 1 h (p < 0.01), 23 +/- 5% at 1 week (p < 0.001) and 22 +/- 6% (p < 0.05) at 6 weeks (2 weeks after the end of trial treatment). This increase in cardiac output with captopril was mainly due to a substantial and sustained increase in stroke volume, although there was also a small increase in heart rate at 1 week. Both captopril and isosorbide mononitrate reduced systemic vascular resistance within 1 h of the start of treatment, but only the effect of captopril was sustained (perhaps because the three-times daily nitrate regimen induced tolerance). Study treatment was well tolerated, and the incidence of withdrawal of study treatment for hypotension was not significantly different from that with placebo.

CONCLUSIONS

This study indicates that the hemodynamic effects of both captopril and isosorbide mononitrate are well tolerated in the acute phase of myocardial infarction and that captopril favorably influences cardiac function.

Dysphoria and decision making: limited information use for evaluations of multiattribute targets

The hypothesis was that dysphoric relative to nondysphoric individuals use less available, relevant information in decision making because of reduced attentional resources. Dysphoric and nondysphoric Ss evaluated 70 jobs, each of which was described in terms of 5 dimensions (e.g., friendliness of co-workers); there were 5 possible values for each dimension. In both studies, dysphoric relative to nondysphoric Ss used a smaller subset of information, yet did not simplify what information was used and did not combine the information in a more simple manner. The limited information use was not due to dysphoric Ss' systematically ignoring certain dimensions and was evident in both initial and final portions of the task. Dysphoric Ss spent as much time and reported using as much information and investing as much effort as nondysphoric Ss. Reported effort alone was related to actual information use.

Dysphoria and decision making: limited information use for evaluations of multiattribute targets

The hypothesis was that dysphoric relative to nondysphoric individuals use less available, relevant information in decision making because of reduced attentional resources. Dysphoric and nondysphoric Ss evaluated 70 jobs, each of which was described in terms of 5 dimensions (e.g., friendliness of co-workers); there were 5 possible values for each dimension. In both studies, dysphoric relative to nondysphoric Ss used a smaller subset of information, yet did not simplify what information was used and did not combine the information in a more simple manner. The limited information use was not due to dysphoric Ss' systematically ignoring certain dimensions and was evident in both initial and final portions of the task. Dysphoric Ss spent as much time and reported using as much information and investing as much effort as nondysphoric Ss. Reported effort alone was related to actual information use.

Transferable deaths during 1990 for residents of Camberwell Health Authority

Almost one quarter of all deaths among residents of Camberwell District Health Authority during 1990 occurred without the district ('transferable deaths'). These deaths differed from total deaths in that the main cause of study deaths was cancer, and many of these cases died in a hospice with which the district has no direct contact. However, the commonest location of deaths was in hospitals (57% of study death locations) and the majority of these cases died in London teaching hospitals with whom there are major contracts. As the three inner London South East Thames districts, including Camberwell, propose to merge into a single purchasing authority in 1993, all London hospitals where Camberwell residents died in this survey would be covered by the current range of contracts set by the three districts. The study identified a small but important group of deaths from HIV/AIDS, where it seems that people travelled, particularly, to West London for terminal care. A high proportion of deaths from injury and poisoning were either suicides or open verdicts. There were less transferable deaths among the major ethnic minorities in the district than expected, particularly among those of African and Caribbean descent. This may be due to the age and disease patterns in these populations, but may also require study into the need for terminal care among these groups. Transferable deaths are a useful source of epidemiological information and can highlight local health service strengths and deficits.

Clearance of microsphere-entrapped 5-fluorouracil and cytosine arabinoside from the vitreous of primates

Experiments were conducted with biodegradable microspheres containing antimetabolites to assess the release of the drugs from the microspheres into the vitreous cavity of primates. Microspheres containing a mixture of radiolabeled and cold cytosine arabinoside (Ara-C) or 5-fluorouracil (5-FU) were prepared using a solvent evaporation process. The copolymers of poly (lactic) and poly (glycolic) acid (85:15) and drug was dissolved in a mixture of chloroform and acetone. The solutions were then emulsified in an aqueous solution of polyvinyl alcohol and stirred for 24 hours to evaporate the organic solvent. A 0.1 mL aliquot of a suspension of the microspheres was then injected into one eye of eight African Green monkeys. Half received 250 +/- 10 micrograms of Ara-C and the others 375 +/- 15 micrograms of 5-FU. The concentration in the vitreous was then measured by removing a 0.1 mL sample of vitreous at 1, 2, 4 and 11 days after injection. Both drugs released from microspheres were still detectable in the eye 11 days after injection and the clearance kinetics were similar for both drugs. The results indicate that the microspheres appear promising as a slow drug-delivery system for future investigations in conjunction with these and other antimetabolites suitable for the treatment of PVR.

Protective immunization against Epstein-Barr virus-induced disease in cottontop tamarins using the virus envelope glycoprotein gp340 produced from a bovine papillomavirus expression vector

Inoculation with Epstein-Barr virus (EBV) induces malignant lymphomas in the cottontop tamarin (Saguinus oedipus oedipus). This provides an experimental animal model for assessing the efficacy of candidate EBV vaccines which are intended to reduce the incidence of human tumours associated with EBV infection. Previous work has shown that experimental vaccines based on the major virus envelope glycoprotein gp340 prepared from the membranes of EBV-infected cells are effective in protecting cottontop tamarins against EBV-induced disease. However, not all purified gp340 preparations induce protective immunity against EBV lymphoma in the tamarin. In this work, cottontop tamarins were immunized with recombinant gp340, produced using a bovine papillomavirus (BPV) expression vector, and a threonyl muramyl dipeptide adjuvant formulation. Although the recombinant-derived gp340 lacked the membrane anchor sequence of authentic gp340 and was expressed in mouse cells, it was immunogenic and induced virus-neutralizing antibodies. Healthy vaccinated tamarins were protected against EBV-induced disease. The demonstration that a recombinant gp340 product is able to elicit protective immunity in the cottontop tamarin is a significant step in the development of an EBV vaccine because previously it had not been clear whether a recombinant product would have the exact tertiary structure, including the necessary carbohydrate components, to induce protective immunity. A recombinant gp340 vaccine offers various advantages over production of the authentic molecule by laborious biochemical separation, including lower cost and the absence of potentially oncogenic EBV DNA. Therefore, recombinant gp340 produced using the BPV expression vector is suitable for development as a candidate EBV vaccine for a human Phase I trial and beyond.

Prevalence of antibodies to hepatitis C in dialysis patients and transplant recipients with possible routes of transmission

The prevalence of hepatitis C infection and possible predisposing factors was assessed in a renal unit. Of 343 patients at our renal dialysis centre, 37 (10.8%) were anti-HCV positive by a 1st-generation assay (ELISA, Ortho/Chiron) and confirmed positive in 35 (10.2%) with a 2nd-generation test (UBI, New York). Anti-HCV positivity was significantly associated with: duration of renal replacement therapy (P < 0.0001); quantity of blood transfused (P < 0.002); duration of hospital haemodialysis (P = 0.0001); duration with a functional renal transplant (P = 0.039); and aspartate aminotransferase (P < 0.0001). Logistic regression determined the following variables to be independent risk factors: duration of renal replacement therapy with a relative risk of 34.3 for 5-9 years and 87.4 when the duration was in excess of 10 years; renal transplant for less than 1 year (relative risk of 5.0); transfusion in excess of 50 units of blood (relative risk of 11.6). Clinical assessment of anti-HCV-positive patients revealed peripheral signs of chronic liver disease in 40%, hepatomegaly in 34%, and splenomegaly in 9%. This prevalence of hepatitis C infection is similar to other European and North American centres, but contrasts with low prevalence rates reported from dialysis populations in the UK. It adds further support for routine screening of blood and possibly organ donors and implementation of further infection control measures in dialysis centres.

Variability of high-pass resolution perimetry in normals and patients with idiopathic intracranial hypertension

High-pass resolution perimetry, or the "ring test," is a recently developed type of acuity perimetry. To determine its test-retest variability, we studied 10 normals and 10 patients with idiopathic intracranial hypertension (IIH) by testing both eyes four separate times. There was no increase in variability from the center out to 21 degrees of visual field eccentricity. However, there was a significant increase from 22 degrees to 29 degrees in both normals and IIH patients. Unlike light sensitivity threshold automated perimetry, with an increase in threshold level there was no significant increase in variability in either normals or patients. This may be because of the test's method, which thresholds by target size rather than intensity. As expected, there was a large intersubject variability in the patients, with the visual fields being significantly disturbed by analysis of total field, quadrants, concentric rings, and anatomic nerve fiber bundle regions. Surprisingly, there was no significant difference in the total within subject variability of normals and patients. Because with the ring test there is no increase in variability with an increase in threshold, this method of perimetry may have great utility for following patients with disturbed visual fields. The ring test appears to have advantages that promote low test-retest variability.

Skeletal muscle metabolism in heart failure: a 31P nuclear magnetic resonance spectroscopy study of leg muscle

1. The gastrocnemius muscle of seven patients with mild to moderate chronic heart failure and of five healthy control subjects was studied using 31P nuclear magnetic resonance spectroscopy. Spectra were collected at rest and during an incremental, symptom-limited, exercise protocol. Blood flow was measured in the same study during brief interruptions to exercise. 2. The phosphocreatine/(phosphocreatine plus inorganic phosphate) ratio was lower in patients with heart failure than in control subjects at an exercise rate of 1.5 W, although intracellular pH and blood flow were similar. 3. The cytosolic free adenosine 5'-diphosphate concentration was markedly increased in patients with heart failure exercising at 1.5 W compared with control subjects exercising at the same workload. 4. Although the maximum workload achieved by patients with heart failure was less than half of that reached by control subjects, the pH and the phosphocreatine/(phosphocreatine plus inorganic phosphate) ratio were lower in patients with heart failure at maximal load. Blood flow was less at maximal exercise in patients with heart failure than in control subjects in keeping with the reduced work load. 5. The phosphocreatine depletion induced in the gastrocnemius muscle by exercise was more severe than previously described in the forearm of patients with heart failure. 6. Metabolic abnormalities in skeletal muscle may contribute to exercise intolerance in heart failure, particularly during submaximal exercise.

Perceived intimacy of expressed emotion

Research on norms for emotional expression and self-disclosure provided the basis for two hypotheses concerning the perceived intimacy of emotional self-disclosure. The first hypothesis was that the perceived intimacy of negative emotional disclosure would be greater than that of positive emotional disclosure; the second was that disclosures of more intense emotional states would be perceived as more intimate than disclosures of less intense emotional states for both negative and positive disclosures. Both hypotheses received support when male students in Canada rated the perceived intimacy of self-disclosures that were equated for topic and that covered a comprehensive sample of emotions and a range of emotional intensities. The effects were observed across all the topics of disclosure examined.

Herbal medicine as a cause of combined lead and arsenic poisoning

1. Combined chronic lead and arsenic poisoning was diagnosed in a 33-year-old Korean woman following consumption of a Korean herbal medicine prescribed for haemorrhoids. 2. The patient had malaise, severe difficulty walking, arthralgia, oedema and abdominal pain with diarrhoea. 3. Investigation showed anaemia with basophilic stippling, fragmentation and a raised reticulocyte count. 4. Raised blood and urine lead levels and urine arsenic levels were found. 5. Analysis of the herbal medicine revealed a high lead and arsenic content. 6. Treatment with the newer chelating agent 2,3-dimercaptosuccinic acid was successful, with no detectable side-effects.

Evaluating nursing productivity in child health

As nurses are increasingly concerned with assessing and improving their productivity in a variety of settings, they must make systematic use of an evaluation model. The Discrepancy Evaluation Model (DEM) was used to evaluate the productivity of nurses in child health clinics in five centers in the southeastern United States. The first step in any evaluation is to identify standards against which performance can be measured. In this project, no standards were available, and creating them was the first task. Standards for productivity in child health were developed that accounted for differences in clients and the experience level of nurses, while maintaining quality of care. They were situation specific and allowed for the constraints operating in each of the five centers. Discrepancies between the standards and observed performance were identified and underlying factors examined, resulting in a number of recommendations that could streamline the provision of services and improve nursing productivity. The evaluation process can be applied to public health nursing services in a variety of settings.

Expression of Epstein-Barr virus membrane antigen gp340/220 in mouse fibroblasts using a bovine papillomavirus vector

Epstein-Barr virus (EBV) membrane antigen glycoproteins gp340 and gp220 are encoded by a single gene. We have inserted this gene into a bovine papillomavirus (BPV) vector and expressed gp340/220 in mammalian cells under the control of the mouse metallothionein promoter. The proteins produced were of similar Mr, showed similar antigenic specificity and were transported to the same subcellular location as the authentic gp340/220. The inclusion of heavy metal ions in the medium had no effect on the levels of gp340/220, which were approximately the same as those found in standard EBV-transformed lymphoblastoid cell lines, e.g. B95-8. Cells that expressed gp340/220 were selected by several rounds of fluorescence-activated cell sorting, but on passage they rapidly lost the ability to express this glycoprotein. In contrast to this we found that BPV-transformed cells expressing a truncated version of gp340/220 still produced it at significant levels after extended passage.

Skeletal muscle metabolism during exercise under ischemic conditions in congestive heart failure. Evidence for abnormalities unrelated to blood flow

Previous studies with 31P nuclear magnetic resonance have demonstrated that patients with chronic congestive heart failure often exhibit increased glycolytic metabolism and impaired oxidative phosphorylation in exercising skeletal muscle, but the mechanism for these changes remains unresolved. This study was conducted to determine whether these abnormalities result from impaired blood flow or oxygen delivery. Nine patients with mild-to-moderate congestive heart failure and nine age- and size-matched, healthy control volunteers were studied during repetitive submaximal finger flexion exercise under aerobic and ischemic conditions. Skeletal muscle metabolism was assessed by 31P nuclear magnetic resonance of the flexor digitorum superficialis muscle. During steady-state aerobic exercise at 33% of each subject's predetermined maximum workload, the patients with congestive heart failure exhibited significantly lower pH values (6.65 +/- 0.22 vs. 6.97 +/- 0.09, p less than 0.002) and phosphocreatine concentrations, expressed as [phosphocreatine]/([phosphocreatine] + [inorganic phosphate]) (0.59 +/- 0.14 vs. 0.79 +/- 0.08, p less than 0.002). Similar differences were also present throughout ischemic exercise at the same workload. Based upon these measurements, calculated lactate production and adenosine 5'-triphosphate consumption rates were significantly higher in the patients with congestive heart failure. These results indicate that in many patients with congestive heart failure exercising muscle exhibits increased glycolytic metabolism and appears to be metabolically less efficient in relation to external work performed. These changes cannot be explained by impaired blood flow or oxygen delivery alone.

Recurrent aneurysmal subarachnoid haemorrhage: incidence, timing and effects. A re-appraisal in a surgical series

A series of 510 patients with proven aneurysmal subarachnoid haemorrhage (SAH) is reported. The incidence of recurrent haemorrhage during the period awaiting surgery was 13.7%. There was no significant difference in incidence between good and poor grade patients. Following rebleeding there was an immediate mortality of 34% in good grade patients and 52% in poor grade patients. In the long term only 44.4% of good grade and 8% of poor grade patients made a good recovery following a second bleed as compared to 70.6% and 52.8% respectively for those who did not rehaemorrhage.

Post-ictal blood pressure in aneurysmal subarachnoid haemorrhage

A prospective study in which the effect of the post-ictal systemic blood pressure levels on the outcome following surgically treated aneurysmal subarachnoid haemorrhage (SAH) in 325 patients is reported. No differentiation was made between pre-existing essential and prolonged reactive hypertension. A significant association was found between the trend for rising diastolic blood pressure levels and the tendency towards a poor outcome. There was a similar trend for rising systolic blood pressure levels which did not reach statistical significance. Patients with definite hypertension (blood pressure of 160/95 mmHg or greater) were 1.6 times as likely to have a poor outcome than were those with lower blood pressures.

Skeletal muscle metabolism in patients with congestive heart failure: relation to clinical severity and blood flow

We and others have previously demonstrated excessive phosphocreatine (PCr) depletion and acidosis in skeletal muscle during exercise in patients with congestive heart failure (CHF). In the present study, we performed serial measurements of PCr and pH during gradually incremental flexor digitorum superficialis exercise in 22 patients with CHF and 11 age-matched controls to determine: (1) whether abnormalities were present at the same relative workloads (a comparison that would at least partially compensate for differences in muscle mass), (2) the temporable course of the metabolic changes, (3) the relationship of the metabolic findings to clinical variables, and (4) the relationship of the metabolic abnormalities to forearm blood flow. The patients with CHF had significantly lower [PCr] and pH at all submaximal levels of exercise, and these abnormalities were apparent from the onset of low-level exercise. There was considerable heterogeneity among the patients with CHF with respect to the metabolic findings, with 14 of 22 exhibiting either PCr or pH values more than 2 SDs below normal. Patients whose capacity was more limited during the protocol had lower [PCr], and especially pH, at low loads than did other patients with CHF or the control subjects. The more symptomatic patients and those with more limited bicycle exercise tolerance also had lower pH values. In contrast, there were no significant differences in forearm blood flow between the patients and controls and no relationship between forearm blood and either clinical variables or the metabolic findings. These results indicate that skeletal muscle metabolic abnormalities are present in many patients with CHF and that they are not primarily due to either muscle atrophy or impaired blood flow. These changes may explain in part the marked heterogeneity of symptom status and exercise capacity of patients with similar degrees of cardiac dysfunction.

31P nuclear magnetic resonance evidence of abnormal skeletal muscle metabolism in patients with congestive heart failure

In patients with congestive heart failure (CHF), exercise limitation correlates poorly with central hemodynamic abnormalities, suggesting that additional abnormalities in skeletal muscle blood flow or metabolism play an important pathophysiologic role. Therefore, muscle metabolism was examined by 31P nuclear magnetic resonance (NMR) at rest and during repetitive bulb squeeze exercise in 11 patients with New York Heart Association class II to IV CHF and 7 age-matched control subjects. Serial spectra were obtained at rest, at 2 levels of exercise and during recovery. At rest, the only abnormal finding was an elevated inorganic phosphate (Pi) concentration (5.0 +/- 1.5 vs 3.6 +/- 0.4 mM, p less than 0.01). At the lower exercise level, phosphocreatine (PCr) utilization, which was followed as the ratio of [PCr]/[( PCr] + [Pi]), was greater (0.36 +/- 0.16 vs 0.53 +/- 0.10, p less than 0.02), and pH fell more rapidly and to a lower value (6.38 +/- 0.25 vs 6.85 +/- 0.17, p less than 0.001). At the higher level of exercise, the patients could not work effectively and the group differences narrowed. Compared with control subjects, acidification was disproportionately greater in relation to PCr depletion in patients, further suggesting excessive dependence on glycolytic metabolism. The Pi peak was prominently double in 5 patients, indicating presence of a population of muscle fibers undergoing unusually active glycolysis. PCr resynthesis, a reflection of oxidative phosphorylation, was delayed in 4 patients. These findings indicate that in many patients with CHF, exercising muscle has marked metabolic changes consistent with impaired substrate availability and altered biochemistry.

Survival of patients with congestive heart failure: past, present, and future prospects

Over the past several decades, pharmacologic advances have made it possible to markedly alleviate symptoms in most patients with congestive heart failure. However, the prognosis for these patients remains poor. Five years after the onset of congestive heart failure, only approximately 50% of patients are alive; when cardiac failure develops after myocardial infarction mortality is even higher. Survival rates are only 40% to 60% after 1 year in patients with advanced symptoms who are followed in referral centers. Thirty to fifty percent of deaths are sudden and unexpected. Mortality is highest in patients with severe or progressive symptoms, but it appears to be unrelated to the cause of heart failure or its duration. In general, rate of survival is lowest in patients with the most severe depression of left ventricular function, but no hemodynamic index is capable of providing prognostic information in individual patients. Survival is also reduced in patients with frequent ventricular arrhythmias, marked electrolyte disturbances, and elevated plasma catecholamines, but again, none of these measurements are powerful discriminators between survivors and nonsurvivors. A number of pharmacologic and other interventions have the potential to alter the prognosis of congestive heart failure, either by improving or perhaps even by worsening survival. The pooled data from several short-term controlled trials have raised the possibility that the angiotensin converting-enzyme inhibitors may have a beneficial effect on survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Social determinants of self-poisoning

The non-fatal deliberate taking of overdoses in Cork city during 1982 was investigated from records in the general hospitals. In one of the hospitals, those attending after an overdose were personally interviewed. For both sexes, the greatest incidence of overdoses was in the younger groups; for females, there was a seasonal variation. Those taking overdoses were grouped by electoral wards, and the social characteristics of these wards determined. The frequency varied greatly throughout the city; some wards, particularly in corporation northern estates and part of the city centre, showed a rate of up to three times the average; these areas were the most likely to show social deprivation.

Evaluation of patients for cochlear implant by promontory stimulation. Psychophysical responses and electrically evoked brainstem potentials

The protocol for assessing patients for cochlear implantation at University College Hospital and the Royal National Institute for the Deaf, London, includes a session of electrophysiological tests and electrical stimulation of the cochlea. Electrocochleography is performed with the object of excluding non-organic hearing loss and of clarifying the site of deafness. Using the same transtympanic needle, AC and DC electrical stimulation is performed to establish whether patients perceive a sensation of sound, dynamic range and ability to detect frequency shifts. Tinnitus suppression was produced by AC and DC stimulation. It is likely that AC suppression of tinnitus occurs by a masking effect. Electrically evoked auditory brainstem potentials were recorded in one patient.

Dipyridamole and postoperative ischemic deficits in aneurysmal subarachnoid hemorrhage

Recent evidence has suggested that the delayed cerebral ischemic deficits that often follow surgery for aneurysmal subarachnoid hemorrhage (SAH) may be due to a proliferative vasculopathy. This vascular pathology may result from an interaction between the platelets and the vessel wall. A single-blind controlled trial of dipyridamole administration in 677 patients presenting with SAH (of whom 348 came to surgery) was undertaken to test the hypothesis that the modification of platelet behavior might reduce the incidence of ischemic deficits. Blind independent assessment of the outcome in the surgical group based on the Glasgow Outcome Scale and the specific neurological deficits revealed no significant differences between the control and treatment groups.

Argon laser treatment of an abnormal angle vessel producing recurrent hyphema

Spontaneous hyphema has been linked to many conditions. We describe a patient with recurrent spontaneous hyphema caused by an abnormal angle vessel without associated rubeosis iridis, glaucoma, or other vascular abnormalities as documented by iris fluorescein angiography. After treatment with several sessions of argon laser photocoagulation, the patient has remained asymptomatic during ten months of follow-up.

Performance appraisal system for therapeutic recreation

Therapeutic Recreation professionals continually strive for effective performance standards for their clients. In addition to standards for clients, Therapeutic Recreation Specialists must also develop performance standards for themselves to meet the continual challenge of accountability in the 80's. This paper identifies the need to develop a performance appraisal system as well as the benefits. The elements of the standards include: specificity, observability, measurability, attainment and mutual determination. The paper also reviews the process of assignment of relative weights, categories of review and detailed standards for the Director of Therapeutic Recreation and Therapeutic Recreation Specialist at the Rehabilitation Institute of Detroit.

Possible recurrence of amiodarone pulmonary toxicity following corticosteroid therapy

Amiodarone hydrochloride, a new antiarrhythmic agent, has been associated with pulmonary toxicity characterized by cough, dyspnea and diffuse pulmonary infiltrates. We describe a case of fibrosing alveolitis, diagnosed by lung biopsy, in a patient receiving amiodarone which responded to corticosteroid therapy. The pulmonary symptoms recurred after discontinuing corticosteroids, five months after amiodarone was stopped, and were associated with a persistent amiodarone level. To our knowledge, this recurrence of amiodarone pulmonary toxicity has not been reported previously.

Characterization of human anti-luteinizing hormone-releasing hormone (LRH) antibodies in the serum of a patient with isolated gonadotropin deficiency treated with synthetic LRH

In this report we describe the characteristics of human anti-LRH antibodies detected in the serum of a male patient with isolated gonadotropin deficiency. He had received 90 days of therapy with LRH (1 mg, sc, three times daily) and was then placed on three cycles of intermittent therapy (3 weeks of LRH daily, followed by hCG every 3 days for 15 days). At the start of the fourth cycle of therapy with LRH, he developed urticaria at the site of injection, at sites of previous LRH injections, and at distant sites. Upon direct skin testing, the patient reacted positively to 0.02 ng LRH intradermally. A positive intradermal reaction was induced in a normal adult male by preparing his skin with 0.1 ml of the patient's serum and, 24 h later, injecting 0.2 microgram LRH at that site. A binding factor for LRH was detected in the patient's serum by incubation with [125I]LRH. The serum bound 33% of tracer compared to 6% in control serum. We have detected both immunoglobulin G and immunoglobulin E antibodies against LRH in the patient's serum. We have compared displacement of tracer by synthetic LRH with displacement achieved by a series of analogs. Displacements of tracer by LRH, [Lys8]LRH, [D-Trp6,Pro9-NEt]LRH, [des-Gly10]LRH, and [Phe2]LRH were similar, whereas the potencies of Ac-LRH5-10 and AcLRH2-10 were 0.1% or less.

The effect of altered autonomic tone on alanine induced insulin secretion

The effect of pharmacologically induced altered autonomic tone upon alanine stimulated insulin release was examined in adult norgrel dogs. In control studies, intravenous administration of alanine, 1 gm/kg body weight resulted in a mean rise in plasma insulin concentration from basal levels of 7.4 (+/- 2) MUU/ml to a maximum of 24.5 (+/- 6) muU/ml by 10 minutes after injection. In paired studies, epinephrine infusion or atropine administration had no significant effect on the insulin rise in response to the alanine stimulus. This data indicates that in contrast to a glucose stimulus, the insulin response to the amino acid alanine is not influenced by epinephrine or cholinergic blockade. These studies provide further evidence that alanine acts through alternate pathways, different from those utilized by glucose to effect insulin secretion.

Metabolic effects of clofibrate in insulin-dependent ketosis-prone diabetic man

This study examined the effects of clofibrate therapy on basal plasma substrate and hormone concentrations in ketosis-prone insulin-dependent diabetic man. A double-blind crossover design was utilized during a 3-mo period in which clofibrate treatment (1 g b.i.d.) was compared to that of a lactose placebo (1 g b.i.d.). Our results demonstrate that clofibrate treatment resulted in a significant reduction in the concentration of plasma glucose, ketone bodies, free fatty acids, triglyceride, and cholesterol in diabetic man. These beneficial effects were observed without demonstrable changes in circulating concentrations of insulin and glucagon. These observations suggest that in ketosis-prone diabetic man, clofibrate therapy may provide an adjunct to exogenous insulin administration.

Endogenous glucagon regulation in genetically hyperlipemic obese rats

Glucagon concentration and regulation were examined in the Zucker rat, in which obesity and hyperlipemia are phenotypic expressions of an autosomal recessive gene. Using littermate animals which are phenotypically thin and normolipemic as controls, we observed reduced basal plasma glucagon levels in the obese lipemic rats. In response to fasting, obese lipemic animals inappropriately demonstrated a further reduction in plasma glucagon concentration. In response to pharmacologic glucagon stimulation (arginine), a subnormal rise in plasma glucagon concentration was observed in the obese, lipemic animals. Glucagon suppressibility with exogenous glucose remained intact. The reduced secretion of glucagon may be a consequence of the abnormal elevation in concentration of plasma insulin, free fatty acids, and glucose, which are characteristic of the obese, lipemic animal. A possible role of glucagon deficiency in the evolution or maintenance of the lipemic state is suggested.

Continuous monitoring of arterial oxygen tension using a catheter-tip polarographic electrode in infants

An oxygen electrode mounted in the tip of an umbilical artery catheter was used in 36 newborn infants with severe respiratory illnesses, 28 of whom survived. Thirty-seven electrodes were used. The median age at insertion was 4 hours (range, 30 minutes to 122 hours). Three electrodes failed to work and they were removed or replaced, and two could not be properly evaluated. Thirty-two electrodes functioned satisfactorily for 10 to 190 hours (mean, 75 hours) after a one-point calibration against blood sampled through the catheter. Twenty-two did not need recalibrating before they were removed after 10 to 190 hours (mean, 88 hours. Four of the remaining ten electrodes were recalibrated once after 33 to 97 hours and then functioned until removed 15 to 55 hours later. The other six electrodes failed after 32 to 105 hours (mean, 49 hours). Complications were few. A total of 356 arterial blood samples, obtained after the initial calibration and before any recalibration was necessary, gave a correlation coefficient of 0.93 (P less than .0001) against an independent system for measuring arterial oxygen tension (Pao2) (Radiometer Type E.5046 oxygen electrode). We conclude that the catheter-tip electrode is a safe and reliable instrument for continuously recording Pao2 in newborn infants which much simplifies the management of serious respiratory illnesses.

An analgesic comparison of floctafenine (Idarac) and dihydrocodeine in post-operative pain

A double-blind crossover study comparing floctafenine 200 mg, a new analgesic drug, and dihydrocodeine 60 mg, was performed on 72 patients suffering from post-operative pain. Degree of pain relief by floctafenine was similar to that of dihydrocodeine but the relief afforded by the former was of longer duration. Side-effects associated with dihydrocodeine were statistically higher than those associated with floctafenine. Floctafenine was demonstrated to be an effective analgesic with an insignificant incidence of untoward side-effects.

A comparison of a new analgesic, floctafenine, with dextropropoxyphene and aspirin in post-operative pain

Seventy-seven patients took part in a double-blind crossover trial to compare the effects of floctafenine, dextropropxyhene and aspirin in the relief of post-operative pain. Pain levels were recorded at hourly intervals and pain relief scores calculated. For Dose 1, the difference between the mean pain relief score for patients receiving floctafenin (12.8) and that for patients receiving dextropropoxyphen (6.2) was significant, (p smaller than 0.05) but the difference between the mean score for aspirin (9.2) and that for dextropropoxyphene was not significant. For Dose 2, there were no significant differences between the mean pain relief scores for floctafenine (12.5), for aspirin (10.9) and for dextropropoxyphene (13.2).