Treatment with beta-adrenergic blocking agents after myocardial infarction: from randomized trials to clinical practice

OBJECTIVES

Our aim was to determine the percent of patients with myocardial infarction who are treated with beta-adrenergic blocking agents in dosages proved to be effective in preventing death after a heart attack.

BACKGROUND

In the prospective randomized trials showing that beta-blocker treatment improves survival rates after myocardial infarction, relatively high dosages of these agents were used. However, it is not known whether these dosages are used in current clinical practice.

METHODS

In a retrospective analysis of clinical data from 606 consecutive survivors of myocardial infarction at four university hospitals in three countries, we assessed the number of infarct survivors receiving prospectively defined "effective dosages" of beta-blockers. We defined these dosages as those that demonstrated improved survival rates of infarct survivors who received active drug in large, prospective, double-blind, placebo-controlled trials.

RESULTS

Only 58% of infarct survivors with no contraindications to beta-blockers received these drugs at the time of hospital discharge, and only 11% received dosages equivalent to > 50% of the effective dosages. Independent predictors of failure to prescribe beta-blockers to infarct survivors without contraindications to these drugs were the use of diuretic agents, transient heart failure, impaired left ventricular function and increased patient age. Among patients receiving beta-blockers, only the use of propranolol predicted prescription of a low beta-blocker dosage.

CONCLUSIONS

Failure to prescribe beta-blockers after myocardial infarction is common but in most cases is not due to clear contraindications. Many patients not receiving beta-blockers belong to subgroups that would derive the greatest benefit from such treatment. Finally, even when beta-blockers are prescribed, the dosages used are considerably lower than those proved to be effective in preventing death after myocardial infarction.

Alternative splicing in human retinal mRNA transcripts of an opsin-related protein

An opsin-related gene encodes a putative RPE-retinal G-protein-coupled receptor (RGR) that is most homologous to the visual pigments and invertebrate retinochrome. A splice variant of human RGR mRNA can be demonstrated by the sequence of isolated cDNA clones and by the amplification and analysis of human retinal mRNA. The shortened transcript contains a deletion of 114 nucleotides that correspond exactly to the sequence of exon 6 in the human rgr gene. The predicted RGR variant lacks the putative sixth transmembrane domain and has a calculated molecular weight of 27,726. Variable amounts of a 28-kDa protein were found in the retinas of some individuals by immunoblot assay. Since a similar shortened RGR transcript was not detected in bovine retina or RPE, the RGR variant is not essential for vertebrate vision. Analysis of the structure of the rgr gene and of the sequences of cDNA clones indicates that the truncated mRNA may be produced through alternative splicing of pre-mRNA from which a cassette exon is removed and the predicted RGR variant is radically altered in primary structure.

Recruitment challenges in studying late-life depression: do community samples adequately represent depressed older adults?

Although research on late-life depression is burgeoning, little attention has been given to the sampling and recruitment obstacles encountered in trying to enlist the participation of older adults in such studies. In this article, the authors summarize the response rates of 15 recent epidemiological studies and 100 descriptive studies examining late-life depression among community-dwelling older adults. These studies excluded approximately 25-35% of potential participants. The authors present evidence suggesting that because depressed older adults may be especially likely to refuse research invitations, researchers may overlook or underestimate important correlates of depression. In addition, the authors describe several strategies for enhancing recruitment efforts.

[Potentially dangerous moments in use of esophageal balloon tamponade. 4 case reports with critical analysis of the literature]

In general, balloon tamponade is still part of the therapy of bleeding esophageal varices, despite effective sclerotherapy. Four case reports demonstrate that the application of balloon tamponade may be associated with severe complications. Moreover, a critical analysis of the literature shows a very different handling with respect to volume of gastric balloon, duration of blockade and traction to the tube. To prevent serious side effects, a safe way is described in detail when using balloon tamponade.

Recruitment challenges in studying late-life depression: do community samples adequately represent depressed older adults?

Although research on late-life depression is burgeoning, little attention has been given to the sampling and recruitment obstacles encountered in trying to enlist the participation of older adults in such studies. In this article, the authors summarize the response rates of 15 recent epidemiological studies and 100 descriptive studies examining late-life depression among community-dwelling older adults. These studies excluded approximately 25-35% of potential participants. The authors present evidence suggesting that because depressed older adults may be especially likely to refuse research invitations, researchers may overlook or underestimate important correlates of depression. In addition, the authors describe several strategies for enhancing recruitment efforts.

Distinction between quality and quantity of problem-solving responses among depressed older women

The purpose of this project was to investigate the extent to which depressed and nondepressed community-dwelling older women differed in their problem-solving responses to vignettes describing problematic situations common in this population. Contrary to expectations, the depressed and nondepressed older women showed an equal capacity to follow traditional problem-solving steps. There were differences, however, in the quality of solutions generated for dealing with social isolation and interpersonal conflict as judged by peer evaluators. Further work is needed in understanding the components of effective problem solving most important for adjustment to real-life difficulties.

[Orthotopic liver transplantation with arterial re-anastomosis in the rat--a detailed description of technique and analysis of possible errors]

Liver transplantation (LTX) in the rat is a frequently used transplantation model. In the present study we give a detailed description of the suture technique for all anastomoses, except the bile duct, with arterialization of the transplanted liver over an aortoceliac segment to the recipient's aorta. Using this technique, we finally achieved survival rates of 80%. During the development stages, the main cause of death was an exceedingly long anhepatic time (> 20 min); later on, complications occurred only from insufficient anastomoses. The advantage of the suture technique over the cuff technique is that a more physiological anastomosis is obtained with less trauma to the recipient when using rearterialization. Despite the complicated suture technique, the anhepatic time can be well reduced to below 20 min.

Central hamartoma of the liver in a child

A two-year-old girl was found to have a hamartoma of the liver located centrally in the hilar region. Despite the benign character of this lesion severe biliary obstruction developed rapidly and made surgical therapy necessary. The surgical approach, with reference to the literature, is discussed.

Clonidine for patients with rapid atrial fibrillation

OBJECTIVE

To determine whether clonidine can slow ventricular rate in patients with rapid atrial fibrillation.

DESIGN

Randomized, controlled trial, with a 4-hour follow-up period.

SETTING

Emergency room of a university hospital.

PATIENTS

A consecutive sample of 18 hemodynamically stable patients who were evaluated or treated for rapid atrial fibrillation. Exclusion criteria included acute or terminal illness; current use of antiarrhythmic agents, calcium-channel blockers, or beta-blockers; excessive hypertension; pulmonary, valvular, or pericardial disease; and electrolyte imbalance.

INTERVENTIONS

Patients were randomly assigned to receive either "no treatment" (control group) or clonidine, 0.075 mg orally, at baseline and after 2 hours if heart rate did not decrease by at least 20%.

MEASUREMENTS

Blood pressure was measured by the same nurse in the same arm for 4 consecutive hours, and a full 12-lead electrocardiographic evaluation was done.

MAIN RESULTS

Heart rate decreased to below 100 beats/min in eight of nine patients receiving clonidine compared with two of nine patients in the control group. The difference in the mean decreases in heart rate was 38 beats/min (95% CI, 20 to 56 beats/min). Six patients who were treated with clonidine and one patient in the control group reverted to normal sinus rhythm. Systolic blood pressure decreased slightly in both groups, without significant differences. Clinical follow-up was uneventful.

CONCLUSION

Low-dose clonidine was an easy, efficient, and effective treatment for patients with rapid atrial fibrillation who were hemodynamically stable.

Morphometric Comparisons of Optic Nerve Axon Loss in Acquired Immunodeficiency Syndrome

Axonal degeneration and diminution of the axonal population in the optic nerve have been documented in aging and in various neuro-ophthalmic conditions. We applied morphometric techniques to the postmortem examination of optic nerves obtained from patients with acquired immunodeficiency syndrome. Twelve optic nerves (eight from patients with AIDS and four from age-matched control eyes) were stained with paraphenylenediamine and morphometrically analyzed with a computer-assisted image and measurement system. Degeneration was often severe and was scattered throughout all of the AIDS-affected optic nerves. In the AIDS-affected optic nerves, the mean axonal population was markedly lower than the mean obtained from normal optic nerves (880,000 vs 1,507,000). Despite the approximate 40% loss of axons, mean axonal diameters were not markedly different, suggesting that no particular class of axon was especially susceptible to AIDS-associated degeneration. The extent and pattern of axonal loss in optic nerves of patients with AIDS suggest that the changes may not only be secondary to damage at the retina, but may reflect an AIDS-associated primary optic neuropathy.

[Familial Mediterranean fever]

Familial Mediterranean Fever is a genetically determined disease occurring predominantly in Arabs, Armenians, Jews and very rarely in Turks. It is characterized by moderately elevated body temperature and by abdominal, pulmonary or arthritic complaints. These symptoms are recurrent appearing at short intervals and persisting for not more than two days. Renal amyloidosis may be a complication. Thus, treatment should be continued for life. The pathomechanism of the disease is not clear. Colchicine has been shown to give good symptomatic relief. Surprisingly, the prolonged use of this mitotic poison is virtually devoid of untoward side effects, even in pregnancy and childhood.

[Endoscopy, shockwave lithotripsy and local lysis in complicated pigmentary calculi of extra- and intrahepatic bile ducts]

Endoscopy, extracorporeal shockwave lithotripsy (ESWL) and local lysis with alkaline solution of EDTA and bile salts in water were applied in combination in four patients with extra- and intrahepatic pigment stones as well as calcium bilirubinate covered concrements of the biliary tract. In the first patient (a man aged 80 years) a giant concrement of the bile duct was broken up after ESWL by three weeks of local chemical lysis and the fragments were removed by endoscopy. In the second case (man, aged 72), a nonextractable pigment stone was at first reduced in size by four-day local lysis and then removed endoscopically. Intrahepatic pigment stones were completely removed in the other two patients (boy of 12, man of 62) by local lysis only in 3 and 15 weeks, respectively. Even long-term use of the alkaline solution may not cause any serious side effects. Breaking up of stones after size reduction with ESWL of giant stones, size reduction of intact stones and contact lysis of intrahepatic stones are three important indications for chemical dissolution of biliary tract stones, respectively.

A measure of relational competence for community-dwelling elderly

A measure of relational competence was developed to assess the skills necessary for peer friendship development among the elderly. Participants were required to respond to a series of social problem vignettes that were constructed to tap empathy, assertion, and role-taking skills. Validation data were collected as part of a larger project designed to establish indigenous, elderly peer-support telephone dyads among low-income, community-dwelling elderly women. Results indicated that the measure of relational competence was related to initial friendship formation, telephone conversational skills, and rated social competence as determined by judges' ratings of 2 telephone conversations between participants and staff members. The research illustrates the usefulness of moving away from trait conceptions of social competence to a more focused consideration of particular task demands and the skills needed to solve age-linked social problems.

Facets of support related to well-being: quantitative social isolation and perceived family support in a sample of elderly women

The purpose of this study was to examine the independent and interactive relationships of measures of network embeddedness and perceived social support with mental and physical health measures from responses of a sample of 271 community-dwelling elderly women. Quantitative social isolation was measured as the co-occurrence of low network embeddedness with family and with friends. There was a threshold effect such that quantitatively isolated participants had poorer psychological well-being and functional health than did nonisolated participants. This effect was independent of perceived support levels. The pattern was different for perceived social support. Elderly women with low perceived family support had poorer psychological well-being regardless of perceived support from friends or network embeddedness. Implications are discussed for several unanswered questions in the social support literature, including possible interventions for the quantitatively isolated and for those with low levels of perceived support.

[Effect and correlation of various risk factors in the development of retinopathy of prematurity. A retrospective study of 338 premature infants]

The statistical significance of ophthalmological and pediatric findings in the development of retinopathy of prematurity (ROP) was evaluated in a retrospective study of 338 premature infants. Short gestation time, frequent hypoxia, and low birthweight were strongly correlated with advanced stages of ROP. The influence of Vitamin E treatment, duration of oxygen therapy, and need for transfusions was less significant. Neither multiple births nor the infant's sex had any influence on the development of ROP. Cryotherapy appears to reduce ROP, but the number of cases in the present study was too small to permit statistical analysis.

Attributional style in aggressive adolescent boys

Past research suggests that aggressive children misattribute hostile intentions to peers during ambiguous provocative interactions. This study sought to extend the analysis of attributional differences between aggressive and nonaggressive boys to a sample of court-involved adolescents and their perceptions of interactions involving both peers and adults. Three groups of youngsters (nonoffenders, nonaggressive offenders, and aggressive offenders) participated in a structured interview and provided causal attributions for interpersonal problems commonly faced by teenagers. Results indicated that offenders were more likely than nonoffenders to attribute blame to others in ambiguous problem situations. Among offenders, external, person-centered blame attributions were significantly related to aggressiveness. This relationship was found only in ambiguous situations, and the correlation between such person-centered attributions and aggressiveness was higher in adult-oriented interactions than in peer-oriented ones. Overall, the results suggest that aggressiveness among offenders is associated with an attributional style that is characterized by the tendency to attribute blame for problems in ambiguous interactions to global, dispositional characteristics of others.