[Drug treatment of patients with heart infarcts before and after the acute stage: results of the Heart Infarct Registry Augsburg]

To assess the changes in medications prescribed before and after acute myocardial infarction (AMI), all surviving patients aged 25-74 years registered from 1985-1988 in the Coronary Event Register Augsburg were evaluated by sex, medical history, and drug use before and after the event. For the 1546 hospitalized patients (1181 men, 365 women) utilization of all drug groups is higher for patients with reinfarction than for patients with first-ever AMI. Before AMI, but not on hospital discharge, women received significantly more medications than men and were more frequently treated with diuretics (30%; men 18%), antihypertensive drugs (15%, men 8%) and cardiac glycosides (20%; men 14%). The most frequently used drug groups are nitrates (before AMI: 30%; after AMI: 80%) and calcium antagonists (before AMI: 26%; after AMI 61%). The four years show a significant increase in patients with reinfarction who were treated with platelet aggregation inhibitors (1985: 9%; 1988: 32%), as well as an increase in AMI patients released from hospital with this medication (1985: 38%; 1988: 64%). A concomitant significant decrease in reinfarction rates for men is found in the course of the four years under study. The results indicate a rapid assimilation of the results of clinical trials in practice down to the substance level.

In vivo transfection by hepatitis A virus synthetic RNA

Marmosets injected intrahepatically with nucleic acids (cDNA and RNA transcripts) representing the full-length genome of the wild-type HM-175 strain of hepatitis A virus experienced acute hepatitis and seroconversion to hepatitis A virus capsid proteins. The hepatitis was comparable in severity to that caused by infection with the wild-type virus. The viral cDNA and the hepatitis A virus recovered from the feces of an injected animal contained the same marker mutation. Therefore, intermediate cell culture steps can be omitted and the virulence of a hepatitis A virus encoded by a cDNA clone can be evaluated by direct transfection of marmosets.

Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group

BACKGROUND

It is controversial whether the onset of myocardial infarction occurs randomly or is precipitated by identifiable stimuli. Previous studies have suggested a higher risk of cardiac events in association with exertion.

METHODS

Consecutive patients with acute myocardial infarction were identified by recording all admissions to our hospital in Berlin and by monitoring a general population of 330,000 residents in Augsburg, Germany. Information on the circumstances of each infarction was obtained by means of standardized interviews. The data analysis included a comparison of patients with matched controls and a case-crossover comparison (one in which each patient serves as his or her own control) of the patient's usual frequency of exertion with the last episode of exertion before the onset of myocardial infarction.

RESULTS

From January 1989 through December 1991, 1194 patients (74 percent of whom were men; mean age [+/- SD], 61 +/- 9 years) completed the interview 13 +/- 6 days after infarction. We found that 7.1 percent of the case patients had engaged in physical exertion (> or = 6 metabolic equivalents) at the onset of infarction, as compared with 3.9 percent of the controls at the onset of the control event. For the patients as compared with the matched controls, the adjusted relative risk of having engaged in strenuous physical activity at the onset of infarction or the control event was 2.1 (95 percent confidence interval, 1.1 to 3.6). The case-crossover comparison yielded a similar relative risk of 2.1 (95 percent confidence interval, 1.6 to 3.1) for having engaged in strenuous physical activity within one hour before myocardial infarction. Patients whose frequency of regular exercise was less than four and four or more times per week had relative risks of 6.9 and 1.3, respectively (P < 0.01).

CONCLUSIONS

A period of strenuous physical activity is associated with a temporary increase in the risk of having a myocardial infarction, particularly among patients who exercise infrequently. These findings should aid in the identification of the triggering mechanisms for myocardial infarction and improve prevention of this common and serious disorder.

Assessing the needs of the adult with spina bifida

In recent years this society has heard of the plight of people with spina bifida who have graduated from childrens' to adult services, and of the lack of cohesive medical and counselling services offered to them. In the Manchester area, a joint clinic for adults has recently been set up, consisting of a Neurosurgeon, Nephrologist and Clinical Psychologist. Patients attending are those who attended the joint paediatric clinic who are now 16+ and new referrals from GPs and other consultants. 30 people of appropriate age to attend the clinic were identified, and these were contacted by mail to inquire about the sort of services they would like to receive and any problems they have or foresee for the future. 13 replies were received, 12 people indicating that a joint clinic would be of use to them. Results indicated that a total of 42 contacts with medical, paramedical and care services were lost, and 24 requests were received for contact to be resumed. Replies made it clear that guidance on work, education, social provision and sexual counselling were much in demand. Aids provided for mobility, and facilities for disabled people were not always appropriate for our respondents, who were quite vociferous about what they needed, but did not always know what was available. Conclusions to be drawn are that the joint clinic needs to include links with education, careers officers and counsellors, and that time needs to be made available to effectively meet the needs patients present. The clinic could act as a forum to collate experiences, and highlight the problems of the young disabled adult.

Comparison of long-term health problems following childbirth among Asian and Caucasian mothers

While obstetric problems in Asian women have been documented, little is known about longer term health problems following childbirth. This study compares long-term postpartum morbidity in Asian and Caucasian women who had had an infant at a Birmingham maternity unit between 1978 and 1985. A total of 11,701 women returned the questionnaire asking about their experience of a list of 25 health problems. It was found that backache, frequent headaches, shoulderache and pains and weakness in the arms and legs all occurred more commonly among the 530 Asian women than in Caucasian women, even after standardizing for confounding factors. All these symptoms started within three months of the birth, lasted more than six weeks and had not previously been experienced. Most symptoms persisted for more than a year, and even after several years, many had not resolved. The possible role of vitamin D deficiency and the value of antenatal vitamin D supplements are discussed.

Differences between Japanese infants and Caucasian American infants in behavioral and cortisol response to inoculation

The behavioral and cortisol responses of Japanese infants and Caucasian American infants, 4 months of age, were observed during and following routine inoculation. The Caucasian American group showed a more intense initial affective response and a longer latency to quiet than the Japanese group; the Japanese group showed a greater cortisol response. A 4-group taxonomy was created based on high or low behavioral and cortisol response: high behavior-high cortisol, low behavior-low cortisol, high behavior-low cortisol, and low behavior--high cortisol. There were significant differences between the 2 groups of infants using this taxonomy: Infants in the Caucasian American group were more likely to fall in the high behavior-low cortisol group, while infants in the Japanese group were more likely to fall in the low behavior-high cortisol group.

Identification of an mRNA species which encodes a voltage-operated Ca2+ channel in rat liver mRNA

cDNA which encodes part of the alpha 1-subunit of the rabbit skeletal muscle L-type voltage-operated Ca2+ channel (VOCC cDNA) was employed to search for the presence in whole liver and hepatocytes of poly (A+) RNA homologous to mRNA which encodes VOCCs. Such homologous mRNA would be a candidate for mRNA which encodes the putative hepatocyte receptor-activated Ca2+ inflow system (RACIS). Northern blot analysis showed that poly (A+) RNA prepared from intact liver tissue, but not hepatocytes, contained a poly (A+) RNA species comparable in size to that which encodes the alpha 1-subunit of the L-type VOCC. It is concluded (a) that hepatocytes do not possess VOCCs or that the levels of VOCC poly(A+) RNA in hepatocytes are too low to be detected by Northern analysis and (b) that another cell type present in liver tissue does possess a VOCC. In a low stringency screen of a rat liver cDNA library employing VOCC cDNA as a probe, seven positive cDNA clones were obtained. While regions of the 2.3 kb cDNA insert from one of these clones showed sequence similarities with regions of VOCC cDNA, the 2.3 kb sequence did not appear to encode a Ca2+ channel. The present results suggest that the approach of low stringency cDNA library screening is unlikely to allow isolation of RACIS cDNA.

Psychosocial rehabilitation in schizophrenia: beginnings in acute hospitalization

Schizophrenic patients discharged from acute inpatient settings are often unprepared to function outside the hospital, leading to recidivism and frequent rehospitalization. Social skills training programs addressing this need have hitherto only been developed for use in outpatient or long-term inpatient settings. We describe the development of a social skills training program for application in a short-term acute inpatient unit. Nursing coordinates the program, which is designed for a 3 to 4 week hospitalization and is delivered in an open group setting. The training program emphasizes communication skills, problem solving, affect identification, needs recognition, and social relatedness. The program uses group discussions, writing tasks, physical activity, education, role-play, feed-back, and assignments. Goals include assessment of individual deficits, inculcation of awareness that life-objectives can be identified and achieved, assistance with transition to postdischarge living situation or outpatient treatment program, and development of awareness of one's roles and responsibilities. The evolution and present structure of the program are described and four representative lessons are detailed.

Variation in course of hepatitis E in experimentally infected cynomolgus monkeys

Five cynomolgus monkeys (Macaca fascicularis) developed hepatitis after inoculation with a prototype strain of hepatitis E virus (HEV) from Pakistan. Although all 5 monkeys displayed liver enzyme elevations, viremia, virus secretion in feces, and seroconversion, two different patterns of these parameters were observed. For 4 monkeys, increased alanine aminotransferase (ALT) activity was first observed on days 21-26, viremia occurred before and during enzyme elevation, and the animals seroconverted coincidentally with the end of viremia or shortly thereafter. One of these monkeys had a more severe hepatitis, with peak ALT values more than twice the peak levels of the other monkeys. The fifth monkey developed biphasic hepatitis with peaks of ALT activity on days 26 and 54. In this case, viremia and seroconversion were correlated only with the second peak of enzyme elevation and liver histopathology only with the first peak. Viral shedding in this fifth animal lasted two times longer than in other animals.

Accidental dural puncture in obstetric patients and long term symptoms

OBJECTIVE

To examine the association between accidental dural puncture and long term headache and related symptoms.

DESIGN

Postal questionnaire survey to elucidate new symptoms occurring after childbirth, and linking of these to data in obstetric and anaesthetic case notes. Women were surveyed between 13 months and nine years after delivery.

SETTING

Birmingham Maternity Hospital.

SUBJECTS

4700 women who had delivered their most recent baby under epidural anaesthesia, 74 of whom had suffered an accidental dural puncture.

MAIN OUTCOME MEASURES

Frequencies of new headache or migraine or neck ache starting within three months after childbirth and lasting over six weeks.

RESULTS

Among the 74 women who had had an accidental dural puncture there were 17 (23%) who reported one or more of the above symptoms. By comparison, among those who had had an epidural anaesthetic but no recorded puncture, only 329 (7.1%) reported these symptoms. The duration of the headache or migraine or neck ache in the dural tap group ranged from nine weeks to over eight years. Ten of these women reported still unresolved symptoms.

CONCLUSIONS

Conclusions on causality were tentative. Most women would remember a dural tap, and this might influence their reporting of subsequent symptoms attributable to the event. In addition, detailed characterisation of the symptoms was not available. Nevertheless, the findings provide a clear indication of the need for further study of the possible long term sequelae of accidental dural puncture.

Cholecystectomy: a study of patient satisfaction

A prospective study of 77 patients undergoing open cholecystectomy was undertaken to establish the degree of satisfaction experienced by these patients. Specific symptoms were recorded preoperatively and at one year postoperatively. Two patients died from unrelated diseases during the year of follow-up and were excluded from the analysis. All symptoms inquired about reduced in frequency postoperatively, the best cures being achieved for jaundice, upper abdominal colic, fatty food intolerance and back/shoulder pain. A third of patients developed at least one new symptom during the year of follow-up. Seventy-seven per cent graded themselves either completely or well satisfied. It was not possible to predict from preoperative symptoms those who would be dissatisfied or those who would develop a new symptom. This study refutes recent suggestions that up to 50% of patients are dissatisfied with cholecystectomy and provides data which may be used to counsel patients preoperatively.

Tubular carcinoma of the breast: mammographic appearance

OBJECTIVE

Tubular carcinoma of the breast is an uncommon malignant growth that can have subtle mammographic findings. Tubular carcinoma is usually found incidentally during screening mammography. It can be differentiated from conventional breast cancers by its smallness and the lack of palpable findings on physical examination of the breast. The mammographic findings in patients with pure tubular carcinoma (90% tubular formation or greater on histologic examination) have not been reported in the recent radiologic literature.

MATERIALS AND METHODS

We reviewed the mammographic and sonographic findings and clinical histories of 13 patients with biopsy-proved pure tubular carcinoma. Findings on physical examination of the breast were normal in nine patients.

RESULTS

On mammograms, 11 of the 13 tubular carcinomas appeared as small (1.7-cm diameter or less) spiculated masses. The average tumor diameter measured on mammograms was 0.8 cm in patients with normal results of physical examination of the breasts and 1.2 cm in patients with a palpable mass. In two patients, mammography showed suspicious microcalcifications or normal findings. Sonography was performed in three patients and results were normal.

CONCLUSION

Tubular carcinoma of the breast manifests mammographically as a small spiculated mass. Because of their smallness, tubular carcinomas can be differentiated from other forms of infiltrating ductal carcinoma on mammograms. Tubular carcinomas are most frequently found incidentally at screening mammography. With the growing emphasis on screening mammography, an increase in the detection of this form of breast cancer can be expected.