Clinical and angiographic outcomes after Tsunami coronary stent placement

STUDY AIM

The aim of this study was to determine six months restenosis rate measured by off-line quantitative coronary angiography, and to assess the efficacy and safety of newly developed six cells Tsunami stent system for the treatment of symptomatic, de novo, native coronary artery lesions.

STUDY DESIGN AND METHODS

Between January and August 2001, 100 patients with 120 lesions were included at four clinical sites in this prospective, non-randomized, single arm study. In 35% of the patients two or more stents were implanted, 15% of the lesions were stented with more than one stent and 46% of the lesions were in small vessels (<or= 2.75 mm). The Tsunami stent was available in 10, 15, 20 and 30 mm, length, and 3, 3.5 and 4 mm diameter. Angiographic success rate for stented lesions was 100% (residual diameter stenosis <or= 30%) and procedural success rate was 98%. Mean reference vessel diameter by QCA was 2.83 +/- 0.52, and post-procedural minimal lumen diameter was 2.59+/-0.4. Six months angiographic follow-up was available for 81% of the patients and revealed an in-stent restenosis rate of 13.8% for all lesions and 7.4% for single stented lesions. At 30 days 98% and at 6 months 88% of the patients remained free of major adverse cardiac events.

CONCLUSION

Based on the clinical and angiographic results of the present study we can conclude that the Tsunami stent provides safe and effective percutaneous treatment of obstructive coronary artery disease.

Permanent pacing for complete atrioventricular block after nonsurgical (alcohol) septal reduction in patients with obstructive hypertrophic cardiomyopathy

Nonsurgical septal reduction is a newly developed, catheter-based therapeutic option for patients with drug-refractory obstructive hypertrophic cardiomyopathy. A circumscribed septal infarction is generated to reduce the left ventricular outflow tract gradient. The spontaneous regression of complete atrioventricular block after the procedure and the main complication of the intervention are examined, and treatment with permanent pacing is evaluated.

Myocardial infarction after percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: evaluation by contrast-enhanced magnetic resonance imaging

OBJECTIVES

The aim of this study was to evaluate myocardial infarction induced by percutaneous transluminal septal myocardial ablation (PTSMA) in symptomatic patients with hypertrophic obstructive cardiomyopathy using contrast-enhanced (CE) magnetic resonance imaging (MRI).

BACKGROUND

Contrast-enhanced MRI delineates the extent of myocardial infarction in coronary artery disease, but its role in ethanol-induced infarction has not been established.

METHODS

Cine and CE MRI were performed before and one month after PTSMA in 24 patients. Size and location of the induced infarction were related to left ventricular (LV) mass reduction, enzyme release, volume of ethanol administered, LV outflow tract gradient reduction, and coronary ablation site.

RESULTS

One month after PTSMA, regional hyperenhancement was visualized in the basal interventricular septum in all patients. Mean infarction size was 20 +/- 9 g, corresponding to 10 +/- 5% and 31 +/- 16% of total LV and septal mass, respectively. Total LV mass decreased from 219 +/- 64 to 205 +/- 64 g (p < 0.01), and septal mass from 76 +/- 25 to 68 +/- 22 g (p < 0.01). Total LV mass reduction exceeded septal mass reduction (p < 0.01). Infarction size correlated with peak creatine phosphokinase-MB (beta = 0.67, p < 0.01), volume of ethanol administered (beta = 0.47, p = 0.02), total LV and septal mass reduction (beta = 0.50, p = 0.02; beta = 0.73, p < 0.01), and gradient reduction (beta = 0.63, p < 0.01). Seven patients with exclusively right-sided septal infarction had smaller infarction size and less gradient reduction than remaining patients with left-sided or transmural infarction (p < 0.01). In five of these, PTSMA was performed distal in the target artery.

CONCLUSIONS

Contrast-enhanced MRI allowed detailed evaluation of size and location of septal myocardial infarction induced by PTSMA. Infarction size correlated well with clinical indexes of infarct size.

The natural course of spontaneous miscarriage: analysis of signs and symptoms in 188 expectantly managed women

BACKGROUND

Expectant management is an alternative for curettage in women with a miscarriage.

AIM

To assess the pattern of vaginal bleeding and pain in expectantly managed women with a miscarriage, and to analyse the factors predictive of a relatively quick spontaneous loss of pregnancy.

DESIGN OF STUDY

Part of a study comparing expectant management with surgical evacuation.

SETTING

Two hospitals in Amsterdam.

METHOD

In expectantly managed women with a miscarriage, the pattern of vaginal bleeding and pain and the probability of a spontaneous loss of pregnancy was analysed.

RESULTS

Of the 188 expectantly managed women 95 (51%) experienced a spontaneous loss of their pregnancy. In women with bleeding at inclusion, 52% had a completed miscarriage loss, while of the women without bleeding but with a coincidentally diagnosed non-viable pregnancy during routine ultrasonographic examination, 46% had a completed miscarriage. In the multivariate analysis an increasing bleeding pattern at inclusion was predictive of a relatively quick spontaneous loss of pregnancy. The median daily levels of bleeding and pain were the most prominent during the first 8 days after the start of the bleeding and decreased thereafter.

CONCLUSIONS

Expectant management is effective in 51% of unselected women with a miscarriage. An increasing bleeding pattern is predictive of a relatively quick spontaneous loss of pregnancy in first-trimester miscarriages. The graphical representation of our findings can be used to inform women about the natural course of miscarriages and a well-informed treatment choice.

Sonotherapy, antirestenotic therapeutic ultrasound in coronary arteries: the first clinical experience

We studied the safety and feasibility of intracoronary sonotherapy (IST) and its effect on the coronary vessel at 6 months. Thirty-seven patients with stable or unstable angina were included (40 lesions). The indication was de novo lesion (n = 26), restenosis (n = 2), in-stent restenosis (n = 11), and a total occlusion of a venous bypass graft. After successful angioplasty, IST was performed using a 5 Fr catheter with three serial ultrasound transducers operating at 1 MHz. IST was successfully performed in 36 lesions (success rate, 90%). IST exposure time per lesion was 718 +/- 127 sec. During hospital stay, one patient died due to a bleeding complication. At 6-month follow-up, one patient experienced acute myocardial infarction, eight patients underwent repeat PTCA. No patient underwent CABG. Late lumen loss was 1.05 +/- 0.70 mm with a restenosis rate of 25%. IVUS analysis revealed a neointima burden of 25% +/- 11%. IST can be applied safely and with high acute procedural success. Sonotherapy-related major adverse events were not observed. Late lumen loss and neointimal growth were similar to conventional PTCA approaches. These results justify the initiation of randomized clinical efficacy studies.

Extension of increased atherosclerotic wall thickness into high shear stress regions is associated with loss of compensatory remodeling

BACKGROUND

Atherosclerosis preferentially develops at average low shear stress (SS) locations. SS-related signaling maintains lumen dimensions by inducing outward arterial remodeling. Prolonged plaque accumulation at low SS predilection locations explains an inverse relation between wall thickness (WT) and SS. No data exist on WT-SS relations when lumen narrowing and loss of compensatory remodeling commence.

METHODS AND RESULTS

In 14 patients, an angiographically normal artery (stenosis <50%) was investigated with ANGiography and ivUS (ANGUS) to provide 3D lumen and wall geometry. Selection of segments >5 mm in length, in between side branches, yielded 25 segments in 12 patients. SS at the wall was calculated by computational fluid dynamics. WT smaller than 0.2*lumen diameter was defined as normal. Largest arc of normal WT defined reference cross sections. Lumen area relative to the reference cross sections defined area stenosis (AS). Average segmental AS smaller or greater than 10% defined preserved or narrowed lumen, respectively. Total vessel area relative to the reference defined vascular remodeling (VR). For the preserved lumens (n=11, AS=1.7+/-5.6%, P=NS), axially averaged WT and SS were inversely related (slope, -0.46+/-0.55 mm/Pa, P<0.05) and VR was positive (7+/-9%, P<0.05). Narrowed segments (n=13, 1 excluded, AS=18+/-6%, P<0.05) showed no relation between WT and SS or vascular remodeling.

CONCLUSIONS

In patient coronary arteries, the often-reported inverse WT-SS relationship appears restricted to lumen preservation and positive vascular remodeling. Its disappearance with lumen narrowing suggests a growing importance of non-SS-related plaque progression.

Reduced impact of migraine in everyday life: an observational study in the Dutch Society of Headache Patients

OBJECTIVE

To explore the percentage of patients who report a reduced impact of migraine on their life, and to which factors this improvement can be attributed.

METHODS

Four hundred forty-eight members of the Dutch Society of Headache Patients answered a set of structured questionnaires, including the Migraine-Specific Quality of Life instrument (MSQOL).

RESULTS

Of this group, 70% reported a reduced impact of migraine. The most frequently reported reason for this reduction was a change in medication (77%); in particular, change to a triptan. Other favorable factors included a change in life-style (56%): 42% of patients reported more relaxed coping with migraine, a reduction of stress in general (28%) and of stress related to work (24%), and leading a more regular life-style (21%). In addition, social support was frequently mentioned, particularly that offered by the Dutch Society of Headache Patients (58%), family (46%), and their general practitioner (28%). The patients who reported a reduced impact of migraine had less migraine attacks and a higher quality of life than those who did not report such a reduction.

CONCLUSION

The results confirm that factors that are proven effective in clinical trials on migraine also have these effects outside a formal experimental environment.

Clinical introduction of the Tandemheart, a percutaneous left ventricular assist device, for circulatory support during high-risk percutaneous coronary intervention

BACKGROUND

In patients with poor left ventricular function and high-risk coronary lesions, prolonged ischemia during percutaneous coronary intervention (PCI) may have major hemodynamic consequences. The Tandemheart is a percutaneous left ventricular assist device intended for short-term circulatory support.

METHODS AND RESULTS

The Tandem-heart incorporates 9-17 F. arterial cannulae and a unique 21 F. transseptal cannula and centrifugal bloodpump. Operating at 7500 rpm, the pump withdraws oxygenated blood from the left atrium and delivers up to 4 liters/min to the arterial circulation. As of May 2001, the Tandem-heart was electively employed in three male patients (ages 52, 54 and 56) scheduled for high-risk PCI. The mean time to initial circulatory support was less than 30 minutes. Systemic hemodynamics significantly improved prior to PCI in two patients. Pump flow after one hour ranged from 2.43 to 3.8 liters/min (mean 3.17 liters/min) and duration of support from 23 to 49 hours (mean 33 hours). Procedural success was 100%, with no significant hemolysis or bleeding. Successful weaning was completed in all patients, who have remained free of major cardiac events up to seven months post-PCI.

CONCLUSIONS

In this first clinical experience of elective use of Tandem-heart for circulatory support during high-risk PCI, the device was easily inserted and preserved hemodynamic stability, regardless of the intrinsic cardiac function, creating optimism for more widespread use for this and other indications.

Acute myocardial infarction

Acute myocardial infarction is a common disease with serious consequences in mortality, morbidity, and cost to the society. Coronary atherosclerosis plays a pivotal part as the underlying substrate in many patients. In addition, a new definition of myocardial infarction has recently been introduced that has major implications from the epidemiological, societal, and patient points of view. The advent of coronary-care units and the results of randomised clinical trials on reperfusion therapy, lytic or percutaneous coronary intervention, and chronic medical treatment with various pharmacological agents have substantially changed the therapeutic approach, decreased in-hospital mortality, and improved the long-term outlook in survivors of the acute phase. New treatments will continue to emerge, but the greatest challenge will be to effectively implement preventive actions in all high-risk individuals and to expand delivery of acute treatment in a timely fashion for all eligible patients.

Sirolimus-eluting stent for treatment of complex in-stent restenosis: the first clinical experience

OBJECTIVES

In this study, we assess the value of sirolimus eluting stent (SES) implantation in patients with complex in-stent restenosis (ISR).

BACKGROUND

The treatment of ISR remains a therapeutic challenge, since many pharmacological and mechanical approaches have shown disappointing results. The SESs have been reported to be effective in de-novo coronary lesions.

METHODS

Sixteen patients with severe, recurrent ISR in a native coronary artery (average lesion length 18.4 mm) and objective evidence of ischemia were included. They received one or more 18 mm Bx VELOCITY SESs (Cordis Waterloo, Belgium). Quantitative angiographic and three-dimensional intravascular ultrasound (IVUS) follow-up was performed at four months, and clinical follow-up at nine months.

RESULTS

The SES implantation (n = 26) was successful in all 16 patients. Four patients had recurrent restenosis following brachytherapy, and three patients had totally occluded vessels preprocedure. At four months follow-up, one patient had died and three patients had angiographic evidence of restenosis (one in-stent and two in-lesion). In-stent late lumen loss averaged 0.21 mm and the volume obstruction of the stent by IVUS was 1.1%. At nine months clinical follow-up, three patients had experienced four major adverse cardiac events (two deaths and one acute myocardial infarction necessitating repeat target vessel angioplasty).

CONCLUSIONS

The SES implantation in patients with severe ISR lesions effectively prevents neointima formation and recurrent restenosis at four months angiographic follow-up.

[Percutaneous transluminal coronary angioplasty in 1980-85 and 1995-96: more frequent multivessel disease, fewer reoperations and no change in mortality 1 and 5 years postoperatively]

OBJECTIVE

To describe the characteristics of patients undergoing coronary angioplasty (PTCA) over the past 20 years and the outcome after 1 and 5 years.

DESIGN

Prospective follow-up study.

METHODS

All patients who underwent a first PTCA in the Thorax centre of the Erasmus Medical Centre in Rotterdam during the period from 1 September 1980 through 30 November 1985 (group I) were compared with all patients who likewise underwent such a first PTCA during the period between 1 September 1995 and 31 December 1996 (group II). Data on the patients, the operations, any reoperations and the mortality were obtained from patient records, general practitioners and municipal archives. Cumulative percentages of survival and of not having rePTCA or coronary artery bypass surgery (CABG) were analysed by using the Kaplan-Meier-method.

RESULTS

Group I consisted of 856 patients and group II of 840 patients. The percentage of males decreased over the years from 80% to 69%. The average age increased from 56 to 60 years; the oldest patient in group I was 75 years and the oldest in group II was 87 years. The percentage of patients with multivessel disease increased from 36% to 44%. Stent implantation occurred in 55% of the patients in group II (0% in group I). The necessity for urgent CABG due to unsuccessful PTCA decreased from 9.4% to 1%. After 1 year, the percentage of coronary revascularisations was 28.8% in group I and 22.6% in group II (p = 0.01). The perioperative mortality and the 5-year survival were not significantly different in the two groups (group I: 1.3% and 90%; group II: 2.4% and 88%, respectively). For both groups, higher age, a smaller ejection fraction, more extensive vascular disease and no treatment with statins were independent predictors of a higher mortality after 5 years. In group II, renal function disorders were the most important predictor of higher mortality.

Non-invasive coronary angiography with multislice spiral computed tomography: impact of heart rate

OBJECTIVE

To evaluate the impact of heart rate on the diagnostic accuracy of coronary angiography by multislice spiral computed tomography (MSCT).

DESIGN

Prospective observational study.

PATIENTS

78 patients who underwent both conventional and MSCT coronary angiography for suspicion of de novo coronary artery disease (n=53) or recurrent coronary artery disease after percutaneous intervention (n=25).

SETTING

Tertiary referral centre.

METHODS

Intravenously contrast enhanced MSCT coronary angiography was done during a single breath hold, and ECG synchronised images were reconstructed retrospectively. All coronary segments of > or = 2.0 mm without stents were evaluated by two investigators and compared with quantitative coronary angiography. Patients were classified according to the average heart rate (mean (SD)) into three equally sized groups: group 1, 55.8 (4.1) beats/min; group 2, 66.6 (2.8) beats/min; group 3, 81.7 (8.8) beats/min.

RESULTS

Image quality was sufficient for analysis in 78% of the coronary segments in patients in group 1, 73% in group 2, and 54% in group 3 (p < 0.01). The sensitivity and specificity for detecting significant stenoses (> or = 50% lumen reduction) in these assessable segments were: 97% (95% confidence interval (CI) 84% to 100%) and 96% in group 1; 74% (52% to 89%) and 94% in group 2; and 67% (33% to 90%) and 94% in group 3 (p < 0.05). Accounting for all segments of > or = 2.0 mm, including lesions in non-assessable segments as false negatives, the sensitivity decreased to 82% (28/34 lesions, 95% CI 69% to 91%), 61% (14/23 lesions, 42% to 77%), and 32% (6/19 lesions, 15% to 50%), respectively (p < 0.01).

CONCLUSIONS

MSCT allows reliable coronary angiography in patients with low heart rates.

Threatened miscarriage in general practice: diagnostic value of history taking and physical examination

BACKGROUND

Ultrasonography, the gold standard for establishing a diagnosis in first-trimester vaginal bleeding, is not always readily avaliable. Medical history and gynaecological examination are then used instead, to make a provisional diagnosis.

AIM

To determine the diagnostic value of history taking and physical examination in first-trimester bleeding, to differentiate between patients requiring immediate further diagnostic examination from those in whom an expectant policy will initially suffice.

DESIGN OF STUDY

Prospective population-based cohort study.

SETTING

Seventy-four general practices in Amsterdam.

METHOD

Two hundred and twenty-five patients with first trimester vaginal bleeding were referred for an early pregnancy assessment. The data from 204 patients were analysed. Two diagnostic models were constructed based on symptoms and the results of gynaecological examination to identify diagnostic subgroups relevant to clinical practice.

RESULTS

Model 1, which separates viable pregnancies from other diagnoses, increased pre-test probability from 47% to a post-test probability of 70%. Model 2, which enabled the identification of complete miscarriages, resulted in a post-test probability of 41% of a complete miscarriage, given a pre-test sample probability of 25%. The tentative diagnosis of a general practitioner, based entirely on clinical judgement, turned out to be a poor predictor for the ultrasonographically confirmed diagnosis (pre-test probability of 47% changed to a post-test probability of 58%).

CONCLUSION

This study shows that, in first trimester bleeding, neither statistical prediction models based on signs and symptoms, nor clinical judgement, are valid replacements for ultrasonographic assessment in establishing a diagnosis.

Persistent Inhibition of Neointimal Hyperplasia After Sirolimus-Eluting Stent Implantation

Background— Early results of sirolimus-eluting stent implantation showed a nearly complete abolition of neointimal hyperplasia. The question remains, however, whether the early promising results will still be evident at long-term follow-up. The objective of our study was to evaluate the efficiency of sirolimus-eluting stent implantation for up to 2 years of follow-up.

Methods and Results— Fifteen patients with de novo coronary artery disease were treated with 18-mm sirolimus-eluting Bx-Velocity stents (Cordis) loaded with 140 μg sirolimus/cm 2 metal surface area in a slow release formulation. Quantitative angiography (QCA) and intravascular ultrasound (IVUS) were performed according to standard protocol. Sirolimus-eluting stent implantation was successful in all 15 patients. During the in-hospital course, 1 patient died of cerebral hemorrhage after periprocedural administration of abciximab, and 1 patient underwent repeat stenting after 2 hours because of edge dissection that led to acute occlusion. Through 6 months and up to 2 years of follow-up, no additional events occurred. QCA analysis revealed no significant change in stent minimal lumen diameter or percent diameter stenosis, and 3-dimensional IVUS showed no significant deterioration in lumen volume. In 2 patients, additional stenting was performed because of significant lesion progression remote from the sirolimus-eluting stent.

Conclusion— Sirolimus-eluting stents showed persistent inhibition of neointimal hyperplasia for up to 2 years of follow-up.

Management of miscarriage: a randomized controlled trial of expectant management versus surgical evacuation

BACKGROUND

In many countries, surgical uterine evacuation is the standard treatment for women with a miscarriage, but expectant management has been advocated as an alternative. The choice between the two options cannot be based on published evidence alone, because randomized clinical trials are scarce while generalizability of findings to patients with a strong preference for either management options is unclear.

METHODS

In a randomized controlled trial, the complications and efficacy of either expectant or surgical management for miscarriages were compared, and the results in patients who refused randomization and were managed according to their own preference were studied. In total, 122 patients were randomized and 305 were managed according to their choice.

RESULTS

No differences were found in the number of emergency curettages and complications between expectant and surgical management. Efficacy at 6 weeks was 30/64 (47%) in women allocated to expectant management, and 55/58 (95%) in women allocated to surgical evacuation. After 7 days, 37% of expectantly managed women had a spontaneous complete miscarriage. After 6 weeks, intention-to-treat analysis including cross-overs showed similar effectiveness (92% versus 100%). Results in the preference groups were comparable with those in the randomized groups.

CONCLUSION

In our experience a waiting period of 7 days after diagnosis may prevent 37% of surgical procedures.

Routine intracoronary beta-irradiation. Acute and one year outcome in patients at high risk for recurrence of stenosis

AIMS

Intracoronary radiation is a promising therapy potentially reducing restenosis following catheter-based interventions. Currently, only limited data on this treatment are available. The feasibility and outcome in daily routine practice, however, is unknown.

METHODS AND RESULTS

In 100 consecutive patients, intracoronary beta-radiation was performed with a (90)Strontium system (Novoste Beta-Cathtrade mark) following angioplasty. Predominantly complex (73% type B2 and C) and long lesions (length 24.3+/-15.3 mm) were included (37% de novo, 19% restenotic and 44% in-stent restenotic lesions). Radiation success was 100%. Mean prescribed dose was 19.8+/-2.5 Gy. A pullback procedure was performed in 19% lesions. Geographic miss occurred in 8% lesions. Periprocedural thrombus formation occurred in four lesions, dissection in nine lesions. During hospital stay, no death, acute myocardial infarction, or repeat revascularization was observed. Major adverse cardiac events occurred predominantly between 6 and 12 months after the index procedure with major adverse cardiac event-free survival of 66% at 12 months (one death, 10 Q-wave myocardial infarctions, 23 target vessel revascularizations; ranked for worst event).

CONCLUSION

Routine catheter-based intracoronary beta-radiation therapy after angioplasty is safe and feasible with a high acute procedural success. The clinical 1-year follow-up showed delayed occurrence of major adverse cardiac events between 6 and 12 months after the index procedure.

The environmental pollutant hexachlorobenzene causes eosinophilic and granulomatous inflammation and in vitro airways hyperreactivity in the Brown Norway rat

Based on observations that the persistent environmental pollutant hexachlorobenzene (HCB) induces inflammatory skin lesions and eosinophilic and granulomatous lung pathology as well as in vivo airways hyperresponsiveness to methacholine in the BN/SsNOlaHsd rat (Michielsen et al., Toxicol Appl Pharmacol 172:11-20, 2001), which are features of human Churg-Strauss syndrome (CSS), we have investigated whether HCB induced other features of CSS such as asthma and systemic vasculitis involving the heart and kidneys in this strain of rat. To this end, BN/SsNOlaHsd rats received control feed or feed supplemented with 450 mg/kg HCB. On days 6, 14 or 21, tracheas were isolated to assess non-specific in vitro airways hyperresponsiveness (AHR) to cumulative concentrations of arecoline and serotonin. In addition, lungs were lavaged to count and differentiate lavage cells, and skin, lungs, heart, kidneys, and lymph nodes were processed for histopathological investigation. HCB induced eosinophilic and granulomatous lung pathology in the BN/SsNOlaHsd rat, which became more severe with time and was associated with significant in vitro AHR to arecoline. Moreover, as in CSS-patients, systemic effects on spleen and lymph nodes were observed in HCB-fed BN/SsNOlaHsd rats, as well as development of skin lesions with vascular changes and eosinophilic infiltrates. In contrast, cardiac or renal involvement, frequently seen in CSS-patients, was not seen in HCB-fed rats. More importantly, there were no indications of necrotizing vasculitis, a hallmark feature of CSS, in the lungs and skin of BN/SsNOlaHsd rats. Thus, it is concluded that the persistent environmental pollutant HCB possibly induces a mild or early stage of CSS in the BN/SsNOlaHsd rat that may evolve into fully developed CSS after prolonged exposure to HCB.

Coronary restenosis elimination with a sirolimus eluting stent: first European human experience with 6-month angiographic and intravascular ultrasonic follow-up

AIMS

Coronary stenting is limited by a 10%-60% restenosis rate due to neointimal hyperplasia. Sirolimus is a macrocyclic lactone agent that interacts with cell-cycle regulating proteins and inhibits cell division between phases G1 and S1. The hypothesis tested in this study is that local delivery of sirolimus with an eluting stent can prevent restenosis.

METHODS AND RESULTS

Fifteen patients were treated with 18 mm sirolimus eluting BX VELOCITY stents. Quantitative angiography and three-dimensional quantitative intravascular ultrasound were performed at implantation and at the 6 months follow-up. All stent implantations were successful. One patient died on day 2, of cerebral haemorrhage and one patient suffered a subacute stent occlusion due to edge dissection (re-PTCA, CKMB 42). At 9 months no further adverse events had occurred and all patients were angina free. Quantitative coronary angiography revealed no change in minimal lumen diameter and percent diameter stenosis and hence no in-lesion or in-stent restenosis. Quantitative intravascular ultrasound showed that intimal hyperplasia volume and percent obstruction volume at follow-up were negligible at 5.3 mm(3)and 1.8%, respectively. No edge effect was observed in the segments proximal and distal to the stents.

CONCLUSION

Implantation of a sirolimus-eluting stent seems to effectively prevent intimal hyperplasia.

[Twelve year triage and thrombolysis treatment prior to hospitalization for myocardial infarction patients in the Rotterdam area of the Netherlands: outstanding short-term and long-term results]

OBJECTIVE

To describe the results of thrombolysis prior to hospitalisation in patients with evolving myocardial infarction.

DESIGN

Prospective cohort study.

METHOD

The 'Reperfusion for acute infarcts Rotterdam' (Dutch acronym: REPAIR) programme aims to minimise treatment delay in patients with evolving myocardial infarction by the initiation of thrombolytic therapy prior to hospital admission. For patients with symptoms that indicate a developing myocardial infarction, treatment is initiated immediately by the ambulance personnel at the patient's home, once the diagnosis has been confirmed with the help of a portable 12-lead ECG system. The interval between the onset of symptoms and the thrombolysis infusion was recorded for all patients, as well as any complications which occurred during transportation. The long-term survival was determined using data from the municipal registration.

RESULTS

In the period 1988-2000, 1487 patients were treated using the REPAIR protocol, 80% of these within two hours after the onset of symptoms. In 9 cases (0.6%) a thrombolytic treatment had been initiated, whereas the diagnosis 'myocardial infarction' was not confirmed at the hospital. During transport 40 patients (2.7%) experienced ventricle fibrillation, 25 (1.7%) severe hypotension, and 2 patients (0.1%) died. Mortality at 30 days and at one, five, and ten years was 4.9%, 7.3%, 16.2% en 30.1%, respectively. Patients treated within two hours after the onset of symptoms had lower mortality rates than those treated later: at one year 6.7% versus 9.7%, and at 5 years 14.0% versus 25.1% (Kaplan-Meier estimates; log rank test: p = 0.001).

CONCLUSION

Immediate thrombolytic treatment of patients with a developing myocardial infarction which could be safely initiated by ambulance personnel, resulted in excellent short-term and long-term survival.

On the annoyance caused by impulse sounds produced by small, medium-large, and large firearms

A laboratory study was designed in which the annoyance was investigated for 14 different impulse sound types produced by various firearms ranging in caliber from 7.62 to 155 mm. Sixteen subjects rated the annoyance for the simulated conditions of (1) being outdoors, and (2) being indoors with the windows closed. In the latter case, a representative outdoor-to-indoor reduction in sound level was applied. It was anticipated that the presumed additional annoyance caused by the "heaviness" of the impulse sounds might be predicted from the difference between the C-weighted sound exposure level (CSEL; LCE) and the A-weighted sound exposure level (ASEL; LAE). In the outdoor rating conditions, the annoyance was almost entirely determined by ASEL. The explained variance, r2, in the mean ratings by ASEL was 0.95. In the indoor rating conditions, however, the explained variance in the annoyance ratings by (outdoor) ASEL was significantly increased from r2 = 0.87 to r2= 0.97 by adding the product (LCE-LAE)(LAE-alpha) as a second variable. In combination with a 12-dB adjustment for small firearms, the present results showed that for the entire set of impulse sounds rated indoors with windows closed, the rating sound level, Lr, is given by Lr=LAE +12dB+beta(LCE-LAE)(LAE-alpha), with alpha=45dB and beta=0.015dB(-1). For the outdoor rating condition, the optimal parameter values were equal to alpha=57 dB and, again, beta=0.015 dB(-1). In validation studies, in which the effects of the present rating procedure will be compared to field data, it has to be determined to what extent the constants alpha and beta have to be adjusted.

The mercapturic acid biotransformation pathway of hexachlorobenzene is not involved in the induction of splenomegaly, or skin and lung lesions in the Brown Norway rat

Involvement of the mercapturic acid pathway in the induction of splenomegaly and skin and lung pathology by hexachlorobenzene (HCB) in the rat was investigated by seeking to determine whether pentachloronitrobenzene (PCNB) has the same inflammatory effects as HCB, since both compounds are directly conjugated to glutathione, and further processed into the same mercapturic acid metabolites which are excreted via the urine. Female Brown Norway (BN/SsNO1aHsd) rats at 3 to 4 weeks of age were orally exposed to diets with or without supplementation with 450 mg HCB or equimolar (467 mg) or higher (934 mg) amounts of PCNB per kilogram of diet over 4 weeks. Gross skin lesion development and body weight gains were assessed during exposure and spleen and liver weights as well as histopathologic changes in skin and lung were assessed after exposure. After 3 weeks of exposure, urinary metabolites of the mercapturic acid and oxidative biotransformation pathways were identified using high-performance liquid chromatography (HPLC) and liquid chromatography-mass spectrometry (LC-MS). Oral exposure of the rats to 450 mg/kg HCB resulted in an increase in relative spleen and liver weights as well as in the development of skin and lung pathology in the absence of overall liver toxicity. Equimolar or higher concentrations of PCNB caused none of these effects. Urinary levels of the mercapturic acid N-acetyl-S-(pentachlorophenyl)-cysteine (PCP-NAC), were comparable in HCB- and PCNB-treated rats. Levels of closely related methylsulfide derivatives of PCP-NAC, also generated via the same mercapturic acid pathway, appeared to be significantly higher in PCNB- than in HCB-treated rats, whereas the reverse was true for the urinary levels of the oxidative metabolite pentachlorophenol (PCP). Thus, results indicate that metabolites of the mercapturic acid pathway are not involved in the induction of splenomegaly and skin and lung pathology caused by HCB exposure in BN rats and that the main urinary metabolite of HCB in these BN rats is PCP. Since PCP itself, as well as other cytochrome P450-derived metabolites from HCB, are not likely to be involved in the induction of splenomegaly and skin and lung pathology, it is suggested that either the parent compound HCB or as-yet-unidentified non-P450-generated metabolites are involved in these inflammatory effects of HCB.

A field survey on the annoyance caused by sounds from large firearms and road traffic

Subjective reactions to artillery sounds were determined for over 400 respondents divided among 17 different residential areas. Also, for the same respondents, the subjective effects of road-traffic sounds were determined enabling a comprehensive comparison of the dose-response relations. For the sake of comparison with other field surveys, the noise dose for the shooting sounds was, among other things, expressed as the yearly average C-weighted day-night level (CDNL) and that for the road-traffic sounds was expressed as the A-weighted day-night level (ADNL). Similarly, for both sound types the community response was expressed as the percentage of respondents being "highly annoyed." From the comparison of the two dose-response relationships it could be concluded that for numerically equal day-night levels, the artillery sounds were more annoying than the road-traffic sounds. Overall, the difference was equivalent to the change in annoyance produced by a 5-dB shift in the yearly average day-night levels of the sounds. With equal day-night levels for "downwind" conditions, the artillery and road-traffic sounds were equally annoying. Results from the present highly controlled field survey provided a new opportunity to optimize the parameter values in Schomer's rating procedure y = (1/beta)(LCE-PNSE) + PNSE, in which the noise exposure for impulsive sounds (y) is expressed as the A-weighted SEL of equally annoying vehicle sounds. PNSE represents the point at which the impulsive and vehicle sounds with numerically equal levels are also equally annoying. With PNSE fixed at 103 dB, an optimal solution was found with slope beta set to 1.3. With the previously recommended slope beta = 0.67, the rating sound level for artillery sounds would be underestimated by almost 12 dB.