Ticlopidine and aspirin pretreatment reduces coagulation and platelet activation during coronary dilation procedures

OBJECTIVES

It is unknown whether a therapeutic combination of aspirin (ASA) and ticlopidine might effectively decrease activation of hemostasis.

BACKGROUND

Percutaneous transluminal coronary angioplasty (PTCA), rotational atherectomy and stent implantation are procedures that fracture or ablate endothelium and plaque, a situation that activates hemostasis.

METHODS

In 85 patients undergoing PTCA for a 77.8 +/- 1% stenosis, we measured markers of coagulation and platelet activation (thrombin-antithrombin complexes [TAT], prothrombin fragment 1 + 2 [F1 + 2] serotonin and the presence of circulating activated platelets reacting with monoclonal antibodies against glycoproteins exposed on platelet membranes). Blood samples were drawn from a peripheral vein and from the coronary ostium before the procedures. Both immediately and 10 min after angioplasty, and 10 min afterward, samples were collected from a probing catheter (0.018 in, [0.46 cm]) positioned beyond the stenosis. All patients were being treated with antianginal drugs and ASA, 250 mg/day. Seventy of them had taken ticlopidine, 250 mg, twice daily for < or = 1 day (< or = 24 h) (n = 28) or for > or = 3 days (> or = 72 h) (n = 42). Heparin (150 U/kg) was administered before angioplasty. Thirty patients underwent PTCA; 15 of them were not treated with ticlopidine and 15 were given ticlopidine (> or = 72 h). Thirty-five patients had stent implantation, 20 rotational atherectomy.

RESULTS

Before and during the procedures, there was greater thrombin generation (expressed by higher TAT and F1 + 2 plasma levels) in patients not taking ticlopidine or taking it for < or = 24 h (p < 0.05). Platelet activation and plasma serotonin levels were also significantly higher in the no ticlopidine or < or = 24-h ticlopidine groups.

CONCLUSIONS

The combined use of ticlopidine, ASA and heparin effectively controls activation of coagulation in patients with stable or unstable angina undergoing coronary dilation.

Comparison between metoprolol orally osmotic once daily and metoprolol two or three times daily in suppressing exercise-induced and daily myocardial ischemia

Metoprolol is a widely used anti-ischemic drug with a relatively short half-life. To improve patient' compliance and to provide 24-hour coverage, its once daily ORally OSmotic (OROS) formulation was developed. In this multicenter double-blind study, the anti-ischemic effects of metoprolol OROS given once daily at doses of 190 and 285 mg were compared to the regular metoprolol formulation of 100 mg 2 or 3 times daily. Sixty-five patients with stable coronary artery disease, positive exercise tests, and ischemic episodes during daily activity as recorded by ambulatory electrocardiographic monitoring (AEM) were included. In the OROS group, 23 patients completed all 3 treatment periods. In these patients, the number of myocardial ischemic episodes decreased from 239 on placebo to 128 during the 190 mg/day dose (p < 0.0001) and to 86 during the 285 mg/day treatment period (p < 0.0001). In the metoprolol group, there were 204 episodes at baseline and 142 and 140 during the 100 mg 2 or 3 times daily treatment periods (p < 0.0001 for both). During exercise testing, time to 1-mm ST depression increased significantly in the OROS group from 6.3 minutes at baseline to 7.1 and 9.6 minutes during 190- and 285-mg treatment periods. In the metoprolol group, it increased from 5.8 to 7.2 and 8.2 minutes, respectively. Both formulations of metoprolol were well tolerated. The OROS formulation was highly effective in suppressing daily and exercise-induced ischemia and exerted its effect throughout the 24-hour period.

[Value of plain abdominal radiography for evaluating the patency of LGM caval filters]

OBJECTIVES

To evaluate the value of plain abdominal X-Ray to detect vena Tech LGM filter occlusion or patency during follow-up.

METHODS

Eighty-nine patients were followed in a prospective study for 2 to 6 years after vena Tech LGM filter implantation. The control examination consisted in a clinical examination, a plain abdominal X-Ray (to measure expansion index = diameter/height of the filter and to detect migration and angulation) and a Doppler ultrasonography and/or a cavography to appreciate filter patency.

RESULTS

175 plain abdominal X-Ray, 172 Doppler ultrasonographies and 28 cavographies were done. Sensitivity and specificity of retraction to suspect a filter obstruction were respectively: 82.3% and 86.1%; if expansion index was lower or equal to 0.34 its sensitivity and specificity were 100% and 92.1%. The negative predictive values of retraction and of the association retraction-migration to exclude a filter obstruction were 85.1% and 96%.

CONCLUSION

Absence of migration or retraction on plain abdominal X-Ray during the follow-up is highly predictive of filter patency. This limits the use of Doppler ultrasonography and cavography.

Renal and endocrine effects of flosulide, after single and repeated administration to healthy volunteers

Two double-blind, placebo-controlled, balanced cross-over studies were carried out successively in 8 male normotensive volunteers to investigate the acute and chronic effects of two doses of a novel non-steroidal anti-inflammatory drug flosulide (5 mg b.d. and 25 mg b.d.), on the renin-angiotensin-aldosterone system, linking this to changes in the urinary excretion of prostaglandins. Plasma renin and aldosterone were determined on Days 2 and 9, with the subject supine, after 1 h of rest in the sitting position following 1 h of walking, and 3 h after oral intake of 40 mg furosemide, also in the sitting position. Twenty-four hour urine samples were collected on Days 1 and 8 for the measurement of the electrolytes, aldosterone pH1 and the urinary prostaglandins PGE2, PGF2 alpha, 6-keto-PGF1 alpha and TxB2.

RESULTS

After the first day of treatment with 25 mg b.d. flosulide, the increase in body weight was close to significance (0.86 vs -0.08 kg with placebo). A dose- and time-dependent decrease in both active and inactive plasma renin were observed, whereas the fall in plasma and urinary aldosterone was statistically significant only after the higher dose of flosulide. These changes in the renin-angiotensin-aldosterone system were observed in the absence of oedema. Two out of eight volunteers experienced a strong and immediate reduction in the excretion of prostaglandins but overall the two doses tested did not produce a statistically significant inhibition in renal prostaglandins, especially following repeated dosing. The inhibitory effect of flosulide on renal prostaglandin synthesis was found to be less pronounced after repeated treatment, as documented on Day 9 by the lower inhibition of 6-keto-PGF1 alpha and TxB2.

CONCLUSION

These two studies in normal volunteers, in spite of some methodological limitations, were helpful in order to select doses of flosulide which should be effective and safe in patients during Phase II trials, by examining the inhibitory effect of the drug on renin synthesis and renal prostaglandin synthesis.

Use of perioperative or split-course interstitial brachytherapy techniques for salvage irradiation of isolated local recurrences after conservative management of breast cancer

Treatment of local recurrence after conservative management for breast cancer is mastectomy. When mastectomy is contraindicated or refused, could brachytherapy be a therapeutic alternative for such isolated local relapses (ILR)? From February 1977 to June 1990, 38 patients, previously treated by radiation therapy or by a combination of radiotherapy and surgery for breast cancer, underwent salvage brachytherapy for an ILR. Fifteen patients were treated by limited tumorectomy plus 30 Gy perioperative brachytherapy for a 2.4-cm mean diameter IRL (Group A). Twenty-three patients were treated by exclusive split-course brachytherapy, delivering 60-70 Gy by two implants at 1-month interval, for a 3.9-cm mean diameter IRL (Group B). All patients achieved a clinical complete response after treatment. With a mean follow-up of 40 +/- 24 months, eight patients (21%) experienced local relapse between 9 and 48 months (four patients in Groups A and B). This second local recurrence was isolated in one case and was associated with metastatic disease in seven cases. At 5 years, overall survival was 55% (61% for Group A and and 50% for Group B). Three patients developed local complications requiring mastectomy (skin necrosis, two patients; severe breast pain, one patient). Cosmetic results in locally controlled patients were good in four patients, acceptable in twelve patients, mediocre in nine patients, and nonvaluable in two patients. Both perioperative brachytherapy and exclusive split-course brachytherapy appear to be feasible techniques and may be used occasionally as an alternative therapy to radical mastectomy for ILR.

Comparison of estimates of insulin sensitivity from minimal model analysis of the insulin-modified frequently sampled intravenous glucose tolerance test and the isoglycemic hyperinsulinemic clamp in subjects with NIDDM

Minimal model (MINMOD) analysis of the frequently sampled intravenous glucose tolerance test (FSIVGTT) is dependent on an adequate insulin response to the glucose load. As this is characteristically deficient in subjects with non-insulin-dependent diabetes mellitus (NIDDM), the technique has been modified by the use of an intravenous bolus of insulin. Previous validation of this modification in humans has relied on agreement between insulin sensitivity indexes (SI) estimated from tolbutamide- and insulin-modified tests and not on direct comparison with estimates derived from the isoglycemic glucose clamp. We have compared estimates of insulin sensitivity derived from minimal modeling of a 4-h insulin-modified FSIVGTT and the glucose clamp in subjects with NIDDM. Twelve subjects underwent an insulin-modified FSIVGTT and an isoglycemic hyperinsulinemic clamp in random order 2-4 weeks apart. Fasting plasma glucose (8.4 vs. 9.0 mmol/l) and immunoreactive insulin (IRI) concentrations (104.5 vs. 101.5 pmol/l) were not different between the 2 study days. SI(clamp) was derived from the steady-state glucose infusion rate during the 3rd h of the clamp, corrected for the ambient insulin and glucose concentrations. SI(ivgtt) was derived using MINMOD. SI(ivgtt) was 1.06 +/- 0.18 min-1.mU-1.ml x 10(4), and mean SI(clamp) was 4.97 +/- 0.69 l.min-1/pmol.l-1 x 10(4) (mean +/- SE). SI(ivgtt) was positively correlated with SI(clamp) (r = 0.73, P = 0.004) and negatively correlated with body mass index (r = -0.7, P = 0.005) and fasting IRI(ivgtt) (r = -0.64, P = 0.008). In summary, MINMOD analysis of the insulin-modified FSIVGTT provides a valid measure of insulin sensitivity in subjects with NIDDM.

[Exacerbation of myasthenia gravis by pefloxacin]

Pefloxacine 800 mg single dose was given as routine treatment after a cystomanometric examination to a 45-year-old woman with a 30-month history of generalized myasthenia gravis. One hour after, the patient developed exacerbation of myasthenia gravis with bilateral ptosis and an increased generalized weakness. She experienced a rapid improvement during the next 8 hours and physical examination returned to normal within one day. No additional factors which might have contributed to the exacerbation of myasthenia gravis were found. The report of exacerbation of myasthenia gravis with other antibiotic belonging to the group of fluoroquinolones (ciprofloxacin, norfloxacin and ofloxacin) prompt us to recommend caution with the use of all fluoroquinolones in myasthenic patients.

Plasma treatment effects on the tantalum Strecker stent implanted in femoral arteries of sheep

PURPOSE

To evaluate the effects of plasma treatment, a cleaning process for removal of organic contaminants from the knit-wire surface of tantalum Strecker stents, on biocompatibility and thrombogenicity.

METHODS

A treated or untreated stent was randomly implanted in both femoral arteries of 15 sheep studied for periods of 4 (group 1), 15 (group 2), or 42 (group 3) days. Patency, histological changes, and mechanical effects were compared by means of radiologic and pathologic controls.

RESULTS

Plasma treatment did not influence overall patency (93.3% vs 86.7%), maximal neointimal hyperplasia in groups 2 and 3 (801 +/- 123 vs 733 +/- 179 microns), or media thinning in any group (254 +/- 92 vs 285 +/- 72 microns), but modified the elastic properties of the stents by limiting (p = 0.01) shortening at implantation.

CONCLUSION

Plasma treatment does not affect the biocompatibility and thrombogenicity of Strecker stents implanted in normal femoral arteries of sheep but modifies their elastic properties. Further studies are needed to account for this effect.

[Follow-up of 151 pregnant women exposed to antidepressant treatment (MAOI excluded) during organogenesis]

The Pharmacovigilance and Poisons Center in Lyon undertook an analysis of their data on antidepressant (MAOI excluded) exposure during the first trimester of pregnancy. From 1986 to 1991, 151 prospective enquiries were collected of which 145 exposures occurred during the first trimester of pregnancy. The outcome of pregnancy was known for 114 of these cases. Voluntary or medical abortion was decided in 24 cases, spontaneous abortion occurred in 11 patients and fetal death, unrelated to drug exposure, was noted in one case. Delivery was reported in 78 cases including 69 (88.5%) normal infants, with obstetrical complications not related to the treatment in 7 of these cases. Neonatal complications were noted in 5 (6.4%) cases, including withdrawal symptoms possibly related to the treatment in 3 cases. Congenital abnormalities were identified in 4 cases (5.1%) with one case of major malformation (membranous ventricular septal defect). Such a study is not an exhaustive survey of antidepressant exposure during pregnancy, but a collection of inquiries received by our centre. Even though our study's ability to detect an overall increase in the risk of malformations is too low and limited the extent of our conclusion, our results are in agreement with the literature data as no important increased in major birth defect was observed.

Combined radiation and chemotherapy for invasive transitional-cell carcinoma of the bladder: a prospective study

PURPOSE

To improve the results obtained by cystectomy alone and to determine the possibilities of conservative treatment in invasive bladder cancer, we designed a prospective study using a combination of fluorouracil (5-FU) plus cisplatin and concomitant radiation therapy, followed by either cystectomy or additional chemoradiotherapy.

PATIENTS AND METHODS

Fifty-four patients with stage T2 to T4 operable untreated invasive bladder cancer were entered onto the study. Treatment was begun in all patients by transurethral resection (TUR) and followed by the 5-FU-cisplatin combination with concomitant bifractionated split-course radiation therapy. A control cystoscopy was performed 6 weeks after completion of the neoadjuvant program. Patients with persistent tumor underwent cystectomy. Complete responders were treated by either additional chemoradiotherapy (group A) or cystectomy (group B).

RESULTS

At control cystoscopy, 40 of 54 patients (74%) had a histologically documented complete response. Four responders developed recurrent pelvic disease after a mean follow-up time of 27 +/- 12 months (three in group A and one in group B). Metastatic disease, which developed in 16 patients, occurred more frequently in the nonresponders (71%) than in responders (15%). The disease-free survival rate at 3 years was 62%; it was significantly better in responders (77%) than in nonresponders (23%). There was no difference in survival between groups A and B.

CONCLUSION

This neoadjuvant chemoradiotherapy combination, easy to implement and well tolerated even in elderly patients, provides a high complete response rate. It may prove to be effective in inoperable patients and may be proposed as conservative treatment in patients with a complete response to the initial course of chemoradiation.

Vena Tech-LGM filter: long-term results of a prospective study

Efficiency and tolerance of the Vena Tech-LGM filter were assessed in 142 patients prospectively studied during a 2-6-year follow-up period. No patients were lost to follow-up, and 137 (91.3%) scheduled control examinations were performed. Fifty-three patients died of causes unrelated to thromboembolic disease. Pulmonary embolism was suspected in five surviving patients (3.5%). Sixteen retractions (18.4%), 16 intracaval migrations (18.4%), and one tilt were observed. Filter patency studied at Doppler ultrasonography, with or without phlebocavography, gave the following results according to the Kaplan-Meier actuarial method: 92% patency after 2 years of follow-up, 80% after 4 years, and 70% after 6 years. Vena Tech-LGM filter obstruction was related to retraction (P < 10(-6)) or distal migration (P < .004). Occurrence of trophic disease in the lower limbs during the follow-up period was related to the initial level of deep venous thrombosis (P = .03) and had no relation to the patency of the filter. The filter was effective in preventing pulmonary embolism, with 70% demonstrating long-term patency, and no deleterious effects were imputed to obstructions observed during follow-up.

[Is the urodynamic assessment of enuresis in young adults justified?]

Primary or secondary nocturnal enuresis in adults (over the age of 15 years) is rare, but is associated with considerable psychosocial repercussions. The aim of this retrospective study was to determine whether urodynamic studies have any predictive value for the efficacy of the treatments proposed in these patients. This study was based on 20 patients (8 females and 12 males) between the ages of 15 and 33 years (mean: 23.75 years), studied between 1982 and 1990 with a mean follow-up of 13.35 months. Enuresis was primary in 12 patients and secondary in 8 patients. 11 patients had already received one or more treatments without success. Patients with clinically obvious neurological disease were excluded from the study. The urodynamic assessment included water cystomanometry, water urethromanometry with a perfused catheter and uroflowmetry. In addition to the investigation of other associated disturbances of micturition, the following complementary investigations were performed: urine culture in every case, IVU and/or cystography (n = 18), cystoscopy (n = 3), renal and vesical ultrasonography (n = 1). The urodynamic assessment was abnormal in 16 out of 20 cases: marked detrusor hyperactivity (n = 15), impaired compliance (n = 6), significant urethral instability (n = 7), isolated premature urge (n = 1). 15 patients presented with diurnal disorders dominated by frequency (n = 13), urgency (n = 9) and urge incontinence (n = 4); detrusor hyperactivity was detected in every case. The abnormalities observed on the urodynamic assessment guided treatment, allowing correction of enuresis in 3/4 of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[8 years outcome of 243 trials of coronary angiography performed in the Montreal Institute of Cardiology]

This study reports the long-term outcome of the first 243 patients who underwent coronary angioplasty at the Montreal Heart Institute between February 1980 and March 1983. The average age of the patients was 50 +/- 9 years; one quarter of cases were unstable angina; three quarters of the patients were men. Single vessel coronary disease was present in 83% of patients; the mean ejection fraction was 62%. One segment was dilated in 216 patients and 2 segments in 27 patients. The LAD was dilated in 179 patients, the right coronary in 63 and the left circumflex artery in 20 patients. The average severity of stenosis was 83 +/- 9.5%. Angioplasty was successful in 68.7% of patients. There were no fatalities: 25.5% of patients underwent coronary bypass surgery; 6.2% of patients suffered myocardial infarction. Restenosis was observed in 28% of patients. The average follow-up period was 99 +/- 10 months (average 8 years) and ranged from 7 to 10 years. The survival rate was 98.4% and 90.5% at 5 and 10 years respectively. Survival rates without infarction were 91.8% and 81.3% at 5 and 10 years, and survival without infarction or revascularisation was 73.2% and 60.3% at 5 and 10 years, respectively. During follow-up, 80% of patients were asymptomatic. Nearly a half of patients required antianginal therapy (monotherapy in 65.7% of them). Factors associated with absence of mortality infarction or revascularisation were: female sex, absence of restenosis and less severe stenosis before angioplasty. Using a multivariate analysis, only the degree of stenosis was correlated to the absence of these complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative radiation therapy for cervical lymph node metastases from an occult squamous cell carcinoma

One hundred thirteen patients with cervical metastases from a squamous cell carcinoma and no evidence of the primary tumor were treated for cure by surgery and routine large-field postoperative irradiation. Patients were staged according to the 1987 American Joint Committee on Cancer (AJCC) classification. There were 24 N1, 54 N2, 29 N3, and 6 Nx lesions. One hundred four patients underwent cervical lymph node dissection and 9 had adenectomy. All patients received postoperative external beam therapy to the entire naso-oro-pharyngo-larynx and all cervical lymphatics. The overall nodal failure rate was 13.7%. Nodal failure was significantly correlated with N staging (P = .01) and with the number of histologically involved nodes (P = .05). NOdal failure was 21% when nodes were initially fixed versus 7.5% when they were not (P = .07) and 18% when there was extracapsular spread versus 4.3% when the capsule was intact (P = .11). Eleven patients (9.7%) developed a subsequent primary lesion. In 3 patients (2.6%), this primary was located in the previously irradiated area and, in 2 cases, under the anterior block of lateral fields. Metastases occurred in 18 patients (16%). The five-year overall survival rate was 38%. Survival was correlated with N staging (P less than .02), nodal fixation (P = .05), extracapsular spread (P = .01) and loosely with the number of histologically involved nodes (P = .08). On the contrary, histological differentiation did not influence the local control rate, nor the development of metastases or subsequent primary lesions. Large-field prophylactic radiation therapy appears to be effective in preventing the emergence of initially occult primary lesions. However, control of disease in the neck and survival remain disappointing in patients with advanced nodal disease, even after combined surgery and radiation therapy.

Pharmacokinetics of cadralazine and its hydrazino-metabolite in patients with renal impairment after repeated administration of 5 mg once daily

Since the hydrazino-pyridazine metabolite of cadralazine, CGP 22 639 is believed to contribute to the activity of the drug, its pharmacokinetics and that of cadralazine were investigated in 8 hypertensive patients with renal impairment. The creatinine clearance (CLcr) of patients ranged from 10 to 60 ml/min. The concentrations of cadralazine in plasma and urine, and of CGP 22 639 (plus its possible hydrazones) in plasma were measured after single and repeated administration of 5 mg of cadralazine once daily. A hypotension possibly linked to cadralazine treatment was recorded on day 3 for the patient with CLcr = 10 ml/min. Metabolite concentrations were found to be at least twice as high as in other patients indicating that in this patient, the daily dose of 5 mg was probably too high. The pharmacokinetics of cadralazine were not modified by repeated administration. The drug and its metabolite were eliminated more slowly in patients with low creatinine clearance. The t1/2 of CGP 22 639 was about twice the t1/2 of the unchanged drug. In patients whose CLcr ranged from 19-37 ml/min the mean accumulation factor of apparent CGP 22 639 was 1.7 times that of the unchanged drug. It shows that the apparent CGP 22 639 accumulated more than the unchanged drug. A starting daily dose of 2.5 mg of cadralazine in patients with CLcr < 40 ml/min appears to be suited to take into account the pharmacokinetics of CGP 22 639. This dose can be increased by 2.5 mg steps if the antihypertensive effect is not sufficient (maximum dose with CLcr < 40 ml/min: 10 mg).(ABSTRACT TRUNCATED AT 250 WORDS)

[Reproducibility of the measurement of humeral artery diameter, velocity of carotido-femoral pulse wave and digital pulse wave in normal subjects]

The aim of this study was to assess the intra-observer reproducibility at short and medium term of three non-invasive methods of arterial measurement: in the same day eight volunteers underwent five successive measurements of brachial artery diameter by two dimensional pulsed Doppler of the carotido-femoral pulse wave velocity by a piezoelectric transducer. The measurements were repeated three times at two weeks' interval. The short term (same day) and medium term (after several weeks) reproducibility of the first two methods of measurement was good: 4.69 +/- 2.37%/4.24 +/- 1.90% and 4.09 +/- 1.16%/5.02 +/- 1.71% respectively for brachial artery diameter and carotido-femoral pulse wave velocity. The reproducibility of the method of measuring digital pulse wave velocity was 10.64 +/- 3.50%/11.62 +/- 4.25%, confirming the greater variability of this parameter. Our results with these noninvasive techniques indicate that they may be used to study the arterial system and could be clinically useful in the surveillance of hypertensive patients.

Acute changes in forearm haemodynamics produced by cigarette smoking in healthy normotensive non-smokers are not influenced by propranolol or pindolol

The aim of the present study was to examine the effect of cigarette smoking in healthy non-smokers on blood pressure and forearm haemodynamics after acute oral administration of non-selective beta-adrenoceptor blockers with and without intrinsic sympathomimetic activity, viz. pindolol 15 mg and propranolol 80 mg. A preliminary study was done to compare cigarette smoking and sham smoking to evaluate the time-course of the haemodynamic effects of cigarette smoking. The second experiment was then carried out in the same six volunteers, according to a double-blind randomized placebo-controlled crossover design, to evaluate the possible effect of pre-treatment with beta-adrenoceptor blockers on blood pressure, heart rate and forearm haemodynamics (forearm blood flow, brachial artery diameter and brachio-radial pulse-wave velocity) measured at baseline, during smoking and every five minutes up to 1 h afterwards. No major difference from placebo in blood pressure or forearm haemodynamics was found and pre-treatment with beta-blockers did not prevent the acute vascular effects of cigarette smoking.

Split course interstitial brachytherapy with a source shift: the results of a new technique for salvage irradiation in recurrent inoperable cervical lymphadenopathy greater than or equal to 4 cm diameter in 23 patients

Between June 1981 and December 1986, 23 patients with prior irradiation of the neck for epithelial ENT tumors underwent salvage irradiation for isolated recurrent inoperable cervical lymphadenopathy greater than or equal to 4 cm. The initial irradiation had delivered 45-80 Gy to the cervical lymph nodes. Split course interstitial brachytherapy was used with a source shift in an attempt to decrease treatment complications. The first and second course of the split course implants delivered 35 Gy and 30 Gy at a 1 month interval. The active lines of the second implant were placed parallel to and in between the position of the lines of the first implant. Three patients did not receive the second implant (one death, one disease evolution, one necrosis). For the patient who died between the first and second implants the local control rate could not be determined. The immediate overall local control rate was 73% (16/22) with a later recurrence rate of 62% (10/16), but only in three cases was recurrence within the treated volume (19%-3/16). The local control rate was better (3/9) if the initial lymphadenopathy was greater than or equal to 4 cm less than or equal to 6 cm but worse (3/13) in those with initial lymphadenopathy greater than 6 cm. Survival of these patients overall was poor with 26% survival at 1 year and 13% at 2 years. Tolerance overall was acceptable with tissue necrosis occurring in 36.5% of cases including those with initial skin involvement. If these cases were excluded the necrosis rate was only 15.5%. In this patient population with inoperable recurrent cervical lymphadenopathy in whom a further dose of external irradiation is not possible interstitial brachytherapy should be considered. Our technique of implantation, split over two sessions with a source shift, is practicable with an acceptable toxicity. It may be used even after high dose external beam irradiation and in large volumes of disease, and it gives better results than classical brachytherapy.

Iridium 192 plesiocurietherapy using silicone elastomer plates for extensive locally recurrent breast cancer following chest wall irradiation

From July 1985 to October 1988, 11 patients with prior treatment for breast cancer, and presenting an isolated superficial widespread inoperable chest wall recurrence, underwent plesiocurietherapy for salvage. Most patients (91%) had had a mastectomy. The recurrences developed in tissue that had previously been irradiated to 45-55 Gy in three patients and 65 Gy in eight patients. Salvage was attempted using two or three courses of plesiocurietherapy at monthly intervals to decrease treatment complications. The position of the active sources was maintained parallel but slightly shifted at each application. A total dose of 60 Gy was delivered to a Reference Isodose (R.I.) located 2 to 4 mm under the skin surface. The guide system consisted of plastic tubes inserted at 1.5 cm intervals into flexible silicone plates that were applied to the skin surface to maintain the actives lines 0.5 cm above the skin surface. The high dose sleeves surrounding the actives lines (dose greater than 2 x R.I.) were contained within the thickness of the silicone plate. The mean surface treated was 480 cm2 (range 30-1030 cm2). Two patients had continued progression of the lesions within the treated volume during and after curietherapy and died rapidly of metastatic disease. Nine (89%) patients showed complete regression of treated lesions. But two patients developed a new recurrence outside the treated volume. Complications were acceptable: five patients experienced regressive moderate to severe radiation dermatitis and one had skin necrosis that healed in 2 months. These preliminary results have shown that even when tumor extension and previous treatment theorically counter-indicate further local therapy for locally recurrent breast cancer, it is possible to obtain immediate and, at times, lasting control of local disease using two or three courses of plesiocurietherapy with a source shift.

Arterial and endocrine effects of a combination of an angiotensin converting enzyme inhibitor and a vasodilator in normotensive healthy volunteers

The aim of the present study was to look for possible additive or synergistic effects of the combined oral administration of a single dose of an angiotensin converting enzyme (ACE) inhibitor, benazepril (10 mg) (B), and a long-acting vasodilator, cadralazine (5 mg) (C), on blood pressure, arterial parameters, and active plasma renin. The study was carried out in eight normotensive subjects according to a double-blind, randomized, placebo-controlled, crossover design. Blood pressure (BP), heart rate, humeral artery diameter (D), carotid-femoral pulse-wave velocity (PWV), finger-pulse ratio (FPR), and plasma active renin (PAR) were measured at baseline and every 2 h over 8 h. A significant treatment effect was observed for supine and tilted BP, FPR, PWV, and PAR. The largest decrease in supine systolic and diastolic BP was observed with the combination (10.0 +/- 6.9/7.2 +/- 3.7 mm Hg). Six hours after drug intake, the mean changes in FPR were 0.05 +/- 0.24 (P), -0.06 +/- 0.30 (C), 0.13 +/- 0.32 (B), and 0.28 +/- 0.34 (B + C), and the mean changes in PWV were 0.14 +/- 0.66 m/s (P), 0.09 +/- 0.54 m/s (C), -0.29 +/- 0.50 m/s (B), and -0.55 +/- 0.48 m/s (B + C). PAR was more markedly augmented with the combination of the two drugs (142 +/- 40 pg/ml) than with benazepril alone (90 +/- 62 pg/ml). It was concluded that a single noneffective dose of a vasodilator administered together with an ACE inhibitor in normotensives can lower blood pressure and increase arterial compliance and plasma active renin.

Split course interstitial brachytherapy with a source shift: the results of a new iridium implant technique versus single course implants for salvage irradiation of base of tongue cancers in 55 patients

Between January 1973 and December 1984, 55 patients with prior irradiation of the oropharynx underwent salvage irradiation for recurrent (26 patients) or second cancers (29 patients) of the base of tongue. The initial irradiation had delivered from 45 to 80 Gy to the base of tongue. One of two techniques of Iridium implantation was used for salvage. Single course implants, delivering 60 Gy, were used until June 1981 in a total of 31 patients. After June 1981, split course implants with a source shift were used in 24 patients in the hope of decreasing treatment complications. The first and second course of the split course implants delivered 35 and 30 Gy, respectively, at a 1-month interval. The active lines of the second implant were placed parallel to and between the position of the lines of the first implant. This shift in the source position resulted in a more uniform dose within the treated volume with a 60% reduction in the high dose sleeves. The overall 3-year survival was 19% (28% T less than or equal to 3 cm). The overall local failure rate was 45.5% (25/55). The difference between the local failure rate after single course implants (52%) and after split course implants (37.5%) was not statistically significative. The response observed after the first course of a split course implant proved to be a reliable indication of the probability of achieving local control after a full course of treatment: 2/14 failures (14%) if the response was greater than or equal to 75% versus 7/10 (70%) if the response was less than 75% (p less than 0.01). The only complication noted in the 40 patients achieving immediate local control after either implant technique was mucosal necrosis. The introduction of split course implants was followed by a two and a half fold decrease in the incidence of necrosis: 43% (9/21) in the single course group and 16% (3/19) in the split course group (p = 0.05). Interstitial brachytherapy offers an effective and reasonable option for salvage therapy in patients with recurrent and second cancers occurring in the base of tongue even when the tumor arises in a zone that has previously received high dose irradiation. The use of split course implants with a shift in the position of the active lines at the time of the second implant significantly decreases the risk of radionecrosis.

[Mitral commissurotomy with extracorporeal circulation. Apropos of 200 cases with a median survival of 15 years]

This is a retrospective study of 200 patients, with long-term results operated upon from October 1965 to July 1984. 83% women, 17% men. The mean age was 42.40 +/- 11.03 years. In 87% mitral stenosis was pure and 13% systolic murmur was heard. 60% were in classes III and IV and 40% in classes I and II (NYHA). Hemodynamically mean C.W.P. was 21 +/- 6.27 mm Hg and mean P.A. pressure 30 +/- 9.5 mm Hg. Right anterior thoracotomy was done in every case with canulation of femoral artery and V.C. extracorporeal circulation consisted of a bubble oxgenation (RYGG) and a Roller Pump. In 88.5% both commissures were opened and in 11.5% only the anterolateral commissure. In 58% both papillary muscles were incised, in 15% anterolateral and in 13% posteromedial papillary muscles were incised. In 17% valves or commissures were decalcified. In 5.5% a thrombus was removed from the auricle. Postoperative mortality was 0%. 13% of patients experienced a postoperative complication: 4% hemothorax, 2.5% gaz embolism without sequela, 0.5% lower extremity embolism, 3% pulmonary embolism, 2% phlebitis and 1% gastrointestinal haemorrhage. Postoperatively in 75% of cases no murmur was heard, and in 25% a systolic murmur was found over pericardium. 167 patients were assessed at a mean interval of 129.88 months. 11 patients died at a mean interval of 98.56 +/- 48.56 months with non cardiac cause in 9 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of acetylator status on the haemodynamic effects and pharmacokinetics of cadralazine in healthy subjects

1. Cadralazine is a new antihypertensive agent which causes peripheral vasodilation, probably mediated by a hydrazinopyridazine metabolite. 2. The possible influence of acetylator status on the pharmacokinetics and haemodynamics of the drug was studied in six fast and six slow acetylators over a period of 24 h after administration of a single 10 mg oral dose. 3. There were no differences between the two groups in AUC and Cmax values of cadralazine and apparent metabolite, the latter defined as the sum of the free and conjugated hydrazinopyridazine. Peak plasma concentrations of these compounds were reached after 1 h. Thereafter, the concentration of the metabolite declined more slowly than that of cadralazine. 4. No effects on blood pressure were noted. Changes in heart rate and plasma renin were delayed by 3-5 h with respect to the time-course of drug and metabolite in plasma; maximum responses occurred at 4-6 h after drug administration. The extent of the increase in plasma renin activity was slightly greater in slow than in fast acetylators, but the difference was not significant statistically.

Flow-dependent vasodilation of brachial artery in essential hypertension

Brachial artery hemodynamics including brachial artery diameter (D) and local blood flow velocity (V) was studied in 15 normotensive subjects (NT) and 19 age-matched hypertensive patients (HT) at rest using a bidimensional pulsed Doppler system during a 2-min period of distal circulatory occlusion and during reactive hyperemia. Kinetics of changes in V and D were determined during successive and reproducible maneuvers. V and D decreased significantly during distal circulatory occlusion in both groups. During reactive hyperemia, V reached similar maximum values in both groups, and D increased significantly in NT and HT. Changes in D during reactive hyperemia were positively and significantly correlated with changes in V recorded at the same level. No significant difference was found between the two groups. These results demonstrate noninvasively that there are velocity-dependent variations in the diameter of a large artery in humans and suggest that velocity-dependent vasodilation of the brachial artery is not impaired in essential hypertension.

[Value of continuous monitoring of the electrocardiogram in asymptomatic subjects]

The authors analysed the prevalence of atrioventricular conduction defects and sinus node dysfunction by Holter monitoring in three population groups with similar clinical characteristics: 50 controls (Group I), 17 physically fit subjects with an atrioventricular conduction defect on the resting ECG which was usually asymptomatic (Group II), and 48 professional pilots who were also physically fit but who had no conduction defects on resting ECG (Group III). The 24 hour recordings showed: --a similar incidence of sinus dysrhythmias and atrioventricular conduction defects in the three groups although the frequency of low degree block was a little higher in sportsmen; --a preponderance of the association of first degree block and nocturnal Luciani-Wenckebach periods, sometimes with episodes of Mobitz II block; --the absence of progression to high-degree atrioventricular block. Holter monitoring would therefore seem to be a good method of detecting and following up abnormalities of sinus node function and atrioventricular conduction defects in asymptomatic patients. In addition, it gives a qualitative and quantitative assessment of the recorded changes and provides a means of monitoring their evolution.

[Anomalies in the hemodynamic response to short lasting emotional stress in essential hypertensive subjects]

Systemic hemodynamics, brachial artery diameter (D) and blood flow velocity (v) were determined non-invasively in 26 normotensive subjects (NT) and 34 age- and sex-matched essential hypertensive patients (HT) using pulsed Doppler systems (4 and 8 MHz), at rest and during 2 min periods of mental arithmetic (MA) inducing reproducible changes in blood pressure. During MA in HT, v increased (from 5.3 +/- 1.1 to 8.4 +/- 1.6 cm/sec) to a greater extent (p less than 0.01) than in NT (from 4.9 +/- 0.7 to 6.3 +/- 1.4 cm/sec). Hand exclusion did not change the increase in v in HT and in NT. During MA, D did not change in both groups. Systolic and diastolic arterial pressure increased to a greater extent (p less than 0.01) in HT than in NT, while HR and pulse pressure increased to the same extent in both groups. Since cardiac output and D did not change during MA, instantaneous variations of v likely reflected modulation of arteriolar tone. These results suggest an enhanced vasodilatory response of muscle resistance vessels in HT as compared to NT. The lack of change in D suggest an increase in vascular tone of large arteries likely contributing to the rise in pulse pressure during MA in both groups.

[Influence of acetylation phenotype on the pharmacokinetics and pharmacodynamics data of cadralazine in normotensive subjects]

Cadralazine is a new antihypertensive drug, acting as a peripheral arteriolar vasodilator through its hydrazinopyridazine metabolite. Since this metabolite actively contributes to the activity of the drug, we administered in a double blind randomized study 10 mg/placebo o.d. to 6 healthy fast and 6 slow normotensive acetylators in order to investigate the influence of the acetylator status on hemodynamics and pharmacokinetics. Blood pressure was measured with a DINAMAP apparatus, forearm hemodynamics with a pulsed doppler and central hemodynamics with impedance-cardiography; active renin (RIA), cadralazine and its metabolite (HPLC) were measured during the 11 measurement points. The results were analysed with repeated analysis of variance (ANOVA). Heart rate significantly increased (p less than 0.001), until the 24th hour (p less than 0.05), meanwhile blood pressure and forearm hemodynamics did not change. Cardiac output was increased as a consequence of the elevation in venous return. The rise in active renin paralleled the increase in heart rate with a significant correlation (r' = 0.580, p less than 0.05). The magnitude of the increase was higher in slow than that in fast acetylators, but did no reached the significance. No differences were found for AUC, Cmax and Tmax between the two groups but the active metabolite was eliminated slower than that of cadralazine. The time course of the effects on heart rate and plasma renin was not parallel to the plasma levels of cadralazine and its metabolite. With respect to the power of the study (1-beta = 80 p. 100), no significant differences were found between the two groups.

Pulse pressure and echocardiographic findings in essential hypertension

Blood pressure, carotid-femoral pulse wave velocity and cardiac mass as judged on echocardiography were evaluated in 11 normal subjects and 36 patients with sustained essential hypertension of similar age. The hypertensive patients were divided into two groups of similar age, weight, height and mean arterial pressure: patients in the first group (Group I) had a pulse pressure inferior to 60 mmHg and in the second group (Group II) had a pulse pressure equal or superior to this value. Group II patients had significant higher values for cardiac mass (148.8 +/- 44.3 vs 116.3 +/- 19.8 g/m2; P less than 0.01) (+/- 1 s.d.) than Group I, while mean arterial pressure and pulse wave velocity were similar in the two groups. Stroke volume was significantly higher in Group II than in normal subjects (99.5 +/- 17.1 versus 82.7 +/- 16.9 ml; P less than 0.05). The study findings suggested that the increased pulse pressure in hypertensive patients might influence the development of cardiac hypertrophy independently of mean arterial pressure and aortic distensibility. The increased pulse pressure could reflect a disturbance between ventricular ejection and impedance affecting the ventricle with a resulting increase in pulsatile energy losses and further increase in cardiac mass.

Flow-dependent vasodilation of the brachial artery in essential hypertension: preliminary report

Brachial artery haemodynamics including brachial artery diameter and local blood flow velocity were studied in 10 normotensive subjects and 10 age-matched hypertensive patients. A bidimensional pulsed Doppler system was used at rest, during a 2-min period of distal circulatory occlusion and during reactive hyperaemia. The kinetics of changes in blood flow velocity and brachial artery diameter were determined during successive and reproducible manoeuvres. The two parameters decreased significantly during distal artery occlusion in both groups. During reactive hyperaemia, blood velocity reached similar maximal values in both groups and brachial artery diameter increased significantly in both normotensives and hypertensives. Changes in the brachial artery diameter during reactive hyperaemia were positively and significantly correlated to changes in blood flow velocity recorded at the same level. No significant difference was found between normotensives and hypertensives. This study has provided a demonstration of velocity-dependent variations in the diameter of a large artery in humans; the results suggest that velocity-dependent vasodilation of the brachial artery is not impaired in essential hypertension.

[Efficacy of intravenous sotalol in the treatment of supraventricular tachycardia]

20 patients with supraventricular tachycardia, received one to three intravenous injections of 0.5 mg/kg of sotalol. This group included 8 atrial fibrillations, 5 atrial flutters, 2 systolic tachycardias and 5 junctional tachycardias. Return to a normal sinus rhythm is obtained in 2 of the 8 patients with atrial fibrillation while a decreased heart rate under 100 per minute is noted in 3 of them. Among the 5 patients with atrial flutter, only one returned to a normal sinus rhythm and in 2 the tachycardia decreased. In the 2 patients with systolic tachycardia, the heart rate decreased without return to a normal sinus rhythm while the heart rate decreased in all 5 cases of junctional tachycardia. A left ventricular failure with hypotension, a bradycardia at 30/min. and a transient left bundle branch block were observed during treatment. The bundle branch block is explained by an increased ventricular effective, refractory period induced by this beta-blocker. Intravenous sotalol appears as an interesting alternative in the treatment of supraventricular tachycardias with an efficacy of about 70 p. cent; it is well tolerated if the contraindications of the beta-blockers are respected.

[Flow-dependent vasodilation of the brachial artery in the normotensive and essential hypertensive patient]

Brachial artery hemodynamics including brachial artery diameter (D), local blood flow velocity (V) and local volumic blood flow, was studied in 10 normotensive subjects (NT) and 10 age-matched hypertensive patients (HT) (50 +/- 4 vs 43 +/- 4 years; m +/- SEM; NS), using a bidimensional pulsed doppler system at rest (control period), during a 2 (or 4) mn-period of distal circulatory occlusion (DO) and during the following reactive hyperemia (RH). Kinetics of change in blood flow velocity and diameter were determined during successive and reproducible manoeuvres. V and D decreased significantly during DO. During RH (1) V reached similar maximum values in both groups (after 2 mn DO: NT: from 2.4 +/- 1.1 to 19.0 +/- 6.9 cm/s; HT: from 2.9 +/- 0.8 to 17.2 +/- 7.6 cm/s) and (2) D increased significantly in both groups (after 2 mn DO: NT: from 0.395 +/- 0.016 to 0.450 +/- 0.025 cm; p less than 0.001; HT: from 0.408 +/- 0.018 to 0.467 +/- 0.018 cm; p less than 0.001), reaching levels significantly higher than during the control period. The brachial artery vasodilation observed in both groups (NT: +12 +/- 3 p. 100; HT: +15 +/- 3 p. 100 of initial diameter) was significantly greater (p less than 0.001), than the reproducibility of the diameter measurement (3 +/- 1 p. 100). Mean arterial pressure and heart rate dit not change during the whole investigation. Increasing the duration of DO from 2 to 4 mn further enhanced the reactive blood flow velocity but did not change the magnitude of the reactive brachial artery vasodilation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pulse wave velocity and ambulatory blood pressure in essential arterial hypertension]

Cardiovascular morbidity and mortality of hypertensive patients is mainly related to lesions of large arteries. Arterial distensibility estimated by carotid-femoral pulse wave velocity (PWV) was evaluated in 22 patients with sustained essential hypertension, together with three different methods of blood pressure (BP) measurement: mercury sphygmomanometer, semi-automatic BP recording using the Dinamap apparatus and 24 H ambulatory BP monitoring using the Spacelabs Monitor (5200). Table shows that, while PWV was not correlated with BP measured by mercury sphygmomanometer, it was strongly and positively correlated with BP measured by the other procedures. The best correlation coefficient was noted for the systolic BP measured in the Day Time (7 h-22 h) by the ambulatory method. This study shows that BP Monitoring correlates more strongly than clinic or casual BP with indices of target organ damage. (Table: see text).

[Pulse pressure and echocardiographic parameters in essential arterial hypertension]

We measured systolic, diastolic, mean (MAP) and pulsed (PP) arterial pressures (Dinamap 845 XT), carotid femoral pulse wave velocity (PWV) and cardiac parameters (echocardiography) to evaluate myocardiac mass and indexed cardiac mass to body surface area (IM) in 47 subjects (11 normotensives and 36 with sustained essential hypertension). Hypertensives were allocated between two groups with same age, weight and height, same mean arterial pressure (119.8 +/- 9.1 mmHg, 119.7 +/- 11.9 mmHg, NS) and PWV (11.90 +/- 2.20 m/s, 12.51 +/- 1.83 m/s, NS): group I (22 subjects) with pulsed pressure less than 60 mmHg, group II (14 subjects) with pulsed pressure greater than or equal to 60 mmHg. (Table: see text). Newman-Keuls between group I and group II: p less than 0.01 for cardiac mass and IM, p less than 0.001 for PP. Cardiac mass (p less than 0.01) and indexed mass to body surface area (p less than 0.01) were greater in group II (with pp greater than or equal to 60 mmHg) than in group I.

CONCLUSION

arterial hypertension is linked with left ventricular hypertrophy which is increased when pulsed pressure is enhanced. This fact could give evidence of importance of pulsatory work in cardiac consequence of hypertension.

[Effects of beta-blockers on hemodynamics of the forearm after tobacco stimulation]

In mild hypertension, a betablocker treatment could reduce cardiovascular events. But in smoking men the benefit disappears and this interaction is unexplained. In 6 healthy non smoking men, we studied the effects of acute oral administration of propranolol (80 mg) pindolol (15 mg) and placebo after cigarette smoking (CS) (two cigarettes within 10 minutes). In a double blind cross over randomized study, arterial pressure and heart rate (HR) were recorded within 20 minutes after CS. Brachial artery diameter (D), Local vascular Resistance (RL), Local arterial Compliance (CL) and pulse wave velocity (VOP) were determined non invasively (using a pulsed doppler system) before and 20 mn after CS. Under placebo, mean arterial pressure (PAM), HR and RL increased significantly after CS (+9.2 +/- 3 mmHg, +4.5 +/- 3 b/mn and +36 +/- 14 per cent, respectively). These modifications were not different after propranolol, pindolol or placebo (ANOVA). Arterial distensibility (CL) was decreased after CS and this alteration was not prevented by beta-blockers. Brachial artery diameter was not modified after CS. Our results demonstrate that acute treatment with non selective beta-blockers with or without sympathomimetic intrinsic activity does not prevent haemodynamic modifications induced by cigarette smoking.

[Current treatment regimen in essential arterial hypertension]

The introduction in the treatment of arterial hypertension of angiotensin-converting enzyme inhibitors and calcium inhibitors, as well as the results of extensive multicentric therapeutic trials, suggest that the prescription of antihypertensive drugs will be profoundly altered in the forthcoming years. The "step by step" approach will be abandoned, and each patient will receive one or two drugs chosen for being the most selective and most suitable for his case. These more personalized long-term treatments will be better tolerated, and the greater patient's compliance will make them more effective drugs to the underlying pathology (smoking habits, blood lipid disorders, early arterial lesions) the antihypertensive treatment will have a greater reducing effect on cardiovascular morbidity and mortality.

[Comparison between the ambulatory and occasional determination of the blood pressure]

In this study, we have attempted to determine the link between the occasional measurement of the blood pressure with an Hg sphygmomanometer and the ambulatory pressure, considering different recording periods during the nyctemer. The mean values of the period 8-10 A.M. and more generally of the diurnal period (7 am-10 pm) are close to the values occasionally observed, contrary to the night values and the values of the entire 24 hours. The heart frequency is always well correlated to the mean ambulatory frequency, for the entire period studied. The systolic and mean arterial pressure are also well correlated. On the contrary, there is no meaning when the diurnal period (7 am-10 pm) is reduced to the period of diurnal activity (7 am-7 pm). There is a very strong correlation between the values of the systolic, diastolic, and mean pressures observed during 24 hours and the morning period (8-10 am), giving the impression that this period could be a good reflection of the ambulatory blood pressure of the 24 h.

[Changes in amplitude of the R wave in V5 during a computerized exercise test: value in the diagnosis of coronary insufficiency]

In order to determine the real value of the amplitude variations of the R wave V5 during a stress test, in the recognition of coronary insufficiency, the stress tests of 227 patients were reviewed and compared to the results of coronary angiography. This permitted to find 93 patients with healthy coronaries and 134 patients presenting an involvement of the anterior inter-ventricular artery (AIVA); 37 have a one-vessel disease, 38 have a two-vessel disease, 59 a tri-vessel disease. Quantitative analysis of the modifications of the R wave in V5 during stress, finds mean values of amplitude variations of 1.46 +/- 2.65 mm (p less than 10(-7)) in the reference group; + 1.36 +/- 3.03 mm (p less than 0.01) in patients with a one-vessel disease; +/- 2.02 +/- 2.73 mm (p less than 10(-5)) in patients with two-vessel disease; +/- 1.77 +/- 2.82 mm (p less than 10(-6)) in patients with three-vessel disease. Mean variations are not significantly different from one group to the other and do not permit to individualize a specific evolutive profile in favor of a coronary disease. Considering the absence of alterations or the increase of the amplitude of R in V5 during stress as a pathological response to a coronary insufficiency.(ABSTRACT TRUNCATED AT 250 WORDS)