Outcome in the real-world of coronary high-risk intervention with drug-eluting stents (ORCHID)—A single-center study comparing Cypher™ sirolimus-eluting with Taxus™ paclitaxel-eluting stents

OBJECTIVE

We present real world experience from a single center registry comparing the 6-month outcome of percutaneous coronary intervention (PCI) in unselected high-risk individuals using either sirolimus-eluting (SES) or paclitaxel-eluting stents (PES).

METHODS/RESULTS

We compared clinical outcome at 6 months follow-up in two cohorts of 156 consecutive patients (total n = 312) who underwent SES (June 2002-February 2003) and PES (march 2003-July 2003) implantation. The primary endpoint was a composite of major adverse cardiac events (MACE). Baseline clinical characteristics were well matched. The 6-month target vessel revascularization (TVR) rates were 1.9% (SES) and 2.6% (PES) and MACE rates were similar in the two groups (SES 4.5% vs. PES 3.2%, P = NS). In the PES group, intervention for multivessel disease, bifurcation lesions and in small vessels was more common, and for in-stent restenosis less common, reflecting the impact of drug eluting stents on indications for PCI. The incidence of sub-acute stent thrombosis, related to inadequate antiplatelet therapy in 3 of the 6 cases, was 0.95% with no difference between the two groups.

CONCLUSION

This study confirms the safety and efficacy of SES and PES in unselected high risk patients undergoing PCI. Clinical outcomes of both stents are equivalent at 6 months with low rates of MACE and TVR. These data provide important complementary information to forthcoming randomized studies.

Effect of gravity on liquid plug transport through an airway bifurcation model

Many medical therapies require liquid plugs to be instilled into and delivered throughout the pulmonary airways. Improving these treatments requires a better understanding of how liquid distributes throughout these airways. In this study, gravitational and surface mechanisms determining the distribution of instilled liquids are examined experimentally using a bench-top model of a symmetrically bifurcating airway. A liquid plug was instilled into the parent tube and driven through the bifurcation by a syringe pump. The effect of gravity was adjusted by changing the roll angle (phi) and pitch angle (gamma) of the bifurcation (phi = gamma =0 deg was isogravitational). Phi determines the relative gravitational orientation of the two daughter tubes: when phi not equal to 0 deg, one daughter tube was lower (gravitationally favored) compared to the other. Gamma determines the component of gravity acting along the axial direction of the parent tube: when gamma not equal to 0 deg, a nonzero component of gravity acts along the axial direction of the parent tube. A splitting ratio Rs, is defined as the ratio of the liquid volume in the upper daughter to the lower just after plug splitting. We measured the splitting ratio, Rs, as a function of: the parent-tube capillary number (Cap); the Bond number (Bo); phi; gamma; and the presence of pre-existing plugs initially blocking either daughter tube. A critical capillary number (Cac) was found to exist below which no liquid entered the upper daughter (Rs = 0), and above which Rs increased and leveled off with Cap. Cac increased while Rs decreased with increasing phi, gamma, and Bo for blocked and unblocked cases at a given Cap > Ca,. Compared to the nonblockage cases, Rs decreased (increased) at a given Cap while Cac increased (decreased) with an upper (lower) liquid blockage. More liquid entered the unblocked daughter with a blockage in one daughter tube, and this effect was larger with larger gravity effect. A simple theoretical model that predicts Rs and Cac is in qualitative agreement with the experiments over a wide range of parameters.

Pseudo-hypo aldosteronism Type II

A 50-day-old infant diagnosed as meningitis had persistently elevated serum potassium, low serum bicarbonate and normal serum sodium. She had metabolic acidosis with low TTKG, low serum renin and low normal serum aldosterone with no renal failure or extra renal causes of hyperkalemia. Hence a diagnosis of Type II pseudo-hypoaldosteronism was made. She was started on oral thiazide following which her serum electrolytes normalized.

Presentation and outcome of rhino-orbital-cerebral mucormycosis in patients with diabetes

AIM

To report presentation and outcome of rhino-orbital-cerebral mucormycosis (ROCM) exclusively in patients with diabetes mellitus.

METHODS

Retrospective, non-comparative, interventional analysis of the medical records of 35 patients with ROCM among 22 316 patients with diabetes seen over the last 12 years.

RESULTS

A cohort of 23 men and 12 women with a mean (SD) age of 47.3 (14.4) years (range 18-70 years) was studied. Five patients had type 1 diabetes mellitus, 29 had type 2 diabetes mellitus, and one had secondary diabetes. Nine patients had ROCM as the first clinical manifestation of diabetes. The mean (SD) blood glucose at presentation was 20.6 (8.3) mmol/l (range 10.0 to 53.3 mmol/l) and 17 patients had ketosis/ketoacidosis. Ophthalmic symptoms and signs were pronounced: external ophthalmoplegia (89%), proptosis (83%), visual loss (80%), chemosis (74%), and eye lid gangrene (14%). Non-ophthalmic manifestations included sinusitis (100%), nasal discharge/ulceration (74%), infranuclear VI nerve palsy (46%), palatal necrosis (29%), cerebral lobe involvement (20%), and hemiparesis (17%). Computed tomography/magnetic resonance imaging showed involvement of paranasal sinuses in all patients with ethmoid (86%) and maxillary (80%) sinuses being most frequently involved. Orbital involvement was observed in 80% of patients with cavernous sinus thrombosis in 11%, and internal carotid occlusion and hydrocephalus in 3% each. All were treated with amphotericin B (3-3.5 g) and 26 (74%) patients underwent appropriate surgery. Twenty one patients (68%) survived with a mean (SD) follow up of 39.6 (34.1) months (range 10 months to 11 years). Factors related to poor survival included delay in diagnosis and treatment (p<0.05), facial and/or eye lid gangrene (p<0.05), hemiplegia (p<0.05), cerebral invasion by mucorales (p<0.05), and treatment with amphotericin B alone (p<0.05).

CONCLUSIONS

In patients with diabetes and ROCM, ROCM was the presenting manifestation in one fourth of the patients. Ophthalmic and extensive cerebral involvement predominated in the clinical picture. Delay in treatment due to late presentation and associated complications were major determinants of the survival outcome in these patients.

Pulmonary mucormycosis presenting with recurrent laryngeal nerve palsy

Pulmonary mucormycosis is an uncommon infection and its endobronchial form is rare. Fever, cough, dyspnoea and hemoptysis are the usual presenting symptoms. Hoarseness of voice, a rare manifestation of endobronchial mucormycosis, has been reported earlier but its exact anatomical basis was unclear. We report an instance of polypoid endobronchial mucormycosis and vocal cord paralysis in a patient with type I diabetes and diabetic ketoacidosis.

Polyglandular autoimmune syndrome type 1 without chronic mucocutaneous candidiasis in a 16 year-old male

A 16 year-old boy presented with adrenal crisis and was incidentally found to have features of latent tetany. Also detected were Hashimoto's thyroiditis, alopecia and subnormal T cell function, and he was diagnosed as having polyglandular autoimmune syndrome type 1 (PGA-1), although chronic mucocutaneous candidiasis, a hallmark of PGA-1, was absent. The presentation of several components of this disorder at one time and at this age is uncommon, and the features of overt hypoparathyroidism were probably masked by associated adrenal insufficiency.

Standard cardiac rehabilitation is less effective for diabetics

To assess clinical outcomes and lifestyle modifications in diabetic patients attending a standard cardiac rehabilitation programme following myocardial infarction (MI), a retrospective longitudinal study was undertaken in a district general hospital in the north west of England. A total of 1804 patients attended the cardiac rehabilitation programme over 10 years, of whom 223 (12.4%) had diabetes mellitus. Drugs were underprescribed in all patients, aspirin and beta-blockers especially in diabetics (75.3% vs 90.3%, p < 0.0001; 38.6% vs 60.8%, p < 0.0001). Smoking cessation was poor in diabetics (54.2% vs 69.1%, p < 0.003) and diabetics were less likely to attend at least one session of physiotherapy (26.9% vs 58.6%, p < 0.0001). Diabetics had higher mortality at one year (15.7% vs 5.6%; p < 0.0001), mostly associated with cardiovascular disease (13.4% vs 5.4%, p < 0.0001). Standard cardiac rehabilitation programmes appear to be less effective for patients with diabetes mellitus. We suggest that patients presenting with an existing chronic condition need specialised programmes of rehabilitation to integrate the care of that condition with their recent MI. Aggressive drug therapy following acute MI should also be prescribed in all patients when not contraindicated by other evidence.

A prospective study of sensitivity and specificity of adenosine deaminase estimation in the diagnosis of tuberculosis pleural effusion

We prospectively evaluated the usefulness of adenosine deaminase [ADA] estimation in the diagnosis of tuberculosis [TB] pleural effusion. Seventy five subjects with pleural effusion were studied. Forty eight of them had TB pleural effusion [M:F: 37:11; mean age 33 +/- 14.4 years range 17-76] and the remaining 27 had pleural effusion due to causes other than TB [non-TB group] [M:F: 19:8; mean age 47.3 +/- 16.5 years; range 17-75]. Pleural fluid [PF] ADA levels were significantly higher in TB (n=48; mean 95.8 +/- 57.5 IU/L) compared with non-TB group (n=27; mean 30.7 +/- 27.2 IU/L) [p<0.001]. Serum ADA [S-ADA] levels were also significantly higher in TB (n=45; mean 39.6 +/- 18.3 IU/L) compared with non-TB group (n=26; mean 18.0 +/- 13.7 IU/L) [p<0.001]. PF-ADA levels were higher compared to S-SDA in TB (p <0.001) and non-TB groups [p<0.01]. Using a cut off of 35 IU/L, the sensitivity and specificity of PF-ADA in the diagnosis of TB was computed to be 83.3% and 66.6% respectively. At a cut-off level of 100 IU/L, PF-ADA was found to have a sensitivity 40% and specificity 100%. From this study it is concluded that, using 100 IU/L as the cut-off, it is possible to avoid pleural biopsy to ascertain the diagnosis of TB in as much as 40% of the patients.

Survival of patients with a new diagnosis of heart failure: a population based study

OBJECTIVE

To describe the survival of a population based cohort of patients with incident (new) heart failure and the clinical features associated with mortality.

DESIGN

A population based observational study.

SETTING

Population of 151 000 served by 82 general practitioners in west London.

PATIENTS

New cases of heart failure were identified by daily surveillance of acute hospital admissions to the local district general hospital, and by general practitioner referral of all suspected new cases of heart failure to a rapid access clinic.

INTERVENTIONS

All patients with suspected heart failure underwent clinical assessment, and chest radiography, ECG, and echocardiogram were performed. A panel of three cardiologists reviewed all the data and determined whether the definition of heart failure had been met. Patients were subsequently managed by the general practitioner in consultation with the local cardiologist or admitting physician.

MAIN OUTCOME MEASURES

Death, overall and from cardiovascular causes.

RESULTS

There were 90 deaths (83 cardiovascular deaths) in the cohort of 220 patients with incident heart failure over a median follow up of 16 months. Survival was 81% at one month, 75% at three months, 70% at six months, 62% at 12 months, and 57% at 18 months. Lower systolic blood pressure, higher serum creatinine concentration, and greater extent of crackles on auscultation of the lungs were independently predictive of cardiovascular mortality (all p < 0.001).

CONCLUSIONS

In patients with new heart failure, mortality is high in the first few weeks after diagnosis. Simple clinical features can identify a group of patients at especially high risk of death.

Incidence and aetiology of heart failure; a population-based study

AIMS

To determine the incidence and aetiology of heart failure in the general population.

METHODS AND RESULTS

New cases of heart failure were identified from a population of 151 000 served by 82 general practitioners in Hillingdon, West London through surveillance of acute hospital admissions and through a rapid access clinic to which general practitioners referred all new cases of suspected heart failure. On the basis of clinical assessment, electrocardiography, chest radiography and transthoracic echocardiography, a panel of three cardiologists decided that 220 patients met the case definition of new heart failure over a 20 month period (crude incidence rate of 1.3 cases per 1000 population per year for those aged 25 years or over). The incidence rate increased from 0.02 cases per 1000 population per year in those aged 25-34 years to 11.6 in those aged 85 years and over. The incidence was higher in males than females (age-adjusted incidence ratio 1.75 [95% confidence interval 1.34-2.29, P<0.0001]). The median age at presentation was 76 years. The primary aetiologies were coronary heart disease (36%), unknown (34%), hypertension (14%), valve disease (7%), atrial fibrillation alone (5%), and other (5%).

CONCLUSIONS

Within the general population, new cases of heart failure largely occur in the elderly, and the incidence is higher in men than women. The single most common aetiology is coronary heart disease, but in a third of cases the aetiology cannot be determined on the basis of non-invasive investigation alone. To be relevant to clinical practice, future clinical trials in heart failure should not exclude the elderly.

Frequency of various congenital heart diseases: analysis of 3790 consecutively catheterised patients

A retrospective analysis of 3790 consecutive patients with congenital heart disease (CHD) who underwent haemodynamic and angiographic studies at Sri Jayadeva Institute of Cardiology, Bangalore, from April 1981 to April 1994 has been done. The incidence of various CHD has been compared with that in other series from Asian and Western countries. Out of 6985 patients who underwent haemodynamic studies, 3790 had CHD (54.3%). Approximately 63 percent (2386) of these cases had shunt lesions like atrial septal defect (ASD), ventricular septal defect (VSD) and patent ductus arteriosus (PDA). Among them, 15 percent (367) had pulmonary arterial hypertension of various grades. The overall incidence of pulmonary arterial hypertension is higher than that reported in the Western literature. Corrective surgery was done in approximately 63 percent of cases. Ethnic differences in the incidence of CHD were found in this study when compared to the Eastern and Western literature. Congenital aortic stenosis and coarctation of aorta were less common compared to Western countries and Tetralogy of Fallot was less common compared to Eastern countries.