Community-based perinatal research

A program of clinical perinatal research was established in a community-based hospital in collaboration with private-practice obstetricians and their patients. This longitudinal study, undertaken to investigate the value of a circulating placental protein as an indicator of fetal compromise, enrolled 200 unselected pregnant patients. The project required collection of five blood samples at 16, 20, 24, 28, and 32 weeks' gestation in addition to a level II ultrasound examination at 32 weeks. Baseline and interim prenatal visit data were collected, as were maternal and neonatal data upon delivery. Patients who participated were invariably enthusiastic about their involvement. The physicians and their staff were also generally pleased. We infer from these and other studies a need to provide enhanced educational, participatory opportunities to all pregnant women. We conclude that properly conducted, reasonably funded projects that offer no direct benefit to the patient or physician can be successfully carried out with physicians and their private patients in community hospitals. The potential benefits of developing such extended resources can only enhance medical care and foster satisfaction and cooperation among physicians and patients.

Hypertension due to a renal renin-secreting tumour

We report a case of a 25 year old man referred to our department because of a blood pressure of 162/122 mmHg, found during a general physical examination. A renal renin-secreting tumour was found to be the cause of the hypertension. It had a diameter of 4 cm and was enucleated from the right kidney. Subsequently the blood pressure returned to normal levels. Histological examination revealed a hemangiopericytoma.

Relation between mortality and treated blood pressure in elderly patients with hypertension: report of the European Working Party on High Blood Pressure in the Elderly

OBJECTIVE

To investigate the relation between mortality and treated systolic and diastolic blood pressures.

DESIGN

Randomised double blind placebo controlled trial. Mortality in the two treatment groups was examined in thirds of treated systolic and diastolic blood pressures.

PATIENTS

339 And 352 patients allocated to placebo and active treatment, respectively. The groups were similar at randomisation in sex ratio (70% women), mean age (71.5 years), blood pressure (182/101 mm Hg), and proportion of patients with cardiovascular complications (35%).

MEASUREMENTS AND MAIN RESULTS

In the placebo group total mortality rose with increasing systolic pressure whereas it had a U shaped relation with diastolic pressure, the total lowest mortality being in patients in the middle third of the distribution of diastolic pressure. In the group given active treatment total mortality showed a U shaped relation with systolic pressure and an inverse association with treated diastolic pressure. In both groups cardiovascular and non-cardiovascular mortality followed the same trends as total mortality. The increased mortality in the lowest thirds of pressure was not associated with an increased proportion of patients with cardiovascular complications at randomisation or with a fall in diastolic pressure exceeding the median fall in pressure in each group. In contrast, patients in the lowest thirds of pressure showed greater decreases in body weight and haemoglobin concentration than those in the middle and upper thirds of pressure.

CONCLUSIONS

In patients taking active treatment total mortality was increased in the lowest thirds of treated systolic and diastolic blood pressures. This increased mortality is not necessarily explained by an exaggerated reduction in pressure induced by drugs as for diastolic pressure a U shaped relation also existed during treatment with placebo. In addition, patients in the lowest thirds of systolic and diastolic pressures were characterised by decreases in body weight and haemoglobin concentration, and the patients in the lowest thirds of diastolic pressure taking active treatment also by an increased non-cardiovascular mortality, suggesting some deterioration of general health.

Endocarditis from a dental focus. Importance of oral hygiene in valvar heart disease

Fastidiously growing bacteria more and more are recognised as a source of infectious endocarditis. Over recent years, three new cases of endocarditis caused by Actinobacillus actinomycetemcomitans were diagnosed in our institution. The rise in frequency is possibly secondary to better laboratory skills. Two patients with Actinobacillus (Haemophilus) actinomycetemcomitans endocarditis presented the classical history of preexisting valvar disease together with poor dental hygiene. The third patient had no congenital or rheumatic preexisting lesion to the valves. The distal part of a ventriculo-atrial drainage device had caused microtrauma to the tricuspid valve. The right-sided endocarditis in this patient was complicated by pulmonary septic emboli. Dental origin of the infection was very likely in this patient too. No dental procedure had been performed in the months preceding the endocarditis of our three patients. They presented endocarditis with an oral microorganism in the absence of any dental manipulation. All three had very poor dental hygiene. Better dental care could possibly have prevented this serious complication.

Ablation of ventricular tachycardia of right ventricular origin with low energy shocks

Three shocks of 2 joules (2,000 volts within 0.3 msec) were given to a patient with ventricular tachycardia of right ventricular origin at the site of the earliest activation. A standard 6 Fr USCI mapping catheter was used. After the first shock the cycle length prolonged from 385 to 531 msec. After the second shock, the tachycardia was no longer inducible and it remained so after 1 week. No recurrences were seen during a follow-up period of 8 months. This is the first report demonstrating efficacy of modified low energy shocks for ventricular tachycardia.

Interplay and interference of the carotid baroreceptors, central command, ergoreceptors on the peripheral vascular responses during static exercise

1. The aim of the present study was to examine the influence of the carotid baroreceptors on the peripheral vascular responses during static exercise and its interference with the 'central command' and the ergoreceptors. 2. Ten healthy subjects performed an isometric handgrip with 30% of maximal voluntary contraction for 1.5 min. Five seconds prior to the end of the exercise the arterial circulation to the exercising forearm muscles was occluded for 1.5 min. The carotid baroreceptors were stimulated by neck suction at -40 mmHg for 0.5 min in each period, and also during control and recovery phase. Contralateral forearm and calf blood flow were measured simultaneously with ECG-triggered venous occlusion plethysmography. 3. The present findings suggest that there are 'central command' and ergoreceptors which modulate carotid baroreflex function to the afferent output to the heart and the peripheral circulation.

Isradipine in essential hypertension: the Belgian General Practitioners' Study

Over 200 hypertensive patients were recruited by 37 general practitioners into a single-blind 12-week study to assess the efficacy, tolerability, and safety of isradipine as an antihypertensive, alone and in combination with guanfacine. A total of 212 patients were given isradipine at doses of 1.25 and 2.5 mg twice daily. Twelve hours after the last dose, diastolic blood pressure was reduced to no more than 90 mm Hg in 52.6 percent of patients treated with isradipine alone. After eight weeks of treatment, 30 percent of patients were also given guanfacine 1 mg daily. By Week 12, 67.6 percent of the patients had attained normotension. Compared with placebo, side-effect frequency was higher for flushing and edema with isradipine, and dry mouth was more frequent with added guanfacine. Electrocardiographic examinations and routine laboratory determinations showed no clinically relevant changes. These data indicate that isradipine as monotherapy and in combination with guanfacine is an effective antihypertensive agent. Most patients will continue to participate in a two-year follow-up involving bimonthly clinical visits and half-yearly electrocardiographic examinations and laboratory determinations.

Centaur: the system

This paper describes the organization of the CENTAUR system and its main components. The system is a generic interactive environment. When given the formal specification of a particular programming language-including syntax and semantics — it produces a language specific environment. This resulting environment includes a structure editor, an interpreter/debugger and other tools, all of which have graphic interfaces. CENTAUR is made of three parts: a database component, that provides standardized representation and access to formal objects and their persistent storage; a logical engine that is used to execute formal specifications; an object-oriented man-machine interface that gives easy access to the system's functions. CENTAUR is essentially written in Lisp (Le_Lisp). The logical engine is Prolog (Mu-Prolog). The man-machine interface is built on top of the virtual graphics facility of Le_Lisp, itself primarily implemented on top of X-Windows.

Hepatitis B-associated polyarteritis nodosa in Alaskan Eskimos: clinical and epidemiologic features and long-term follow-up

We analyzed the demographic, clinical, laboratory and histologic features of 13 patients who were diagnosed as having polyarteritis nodosa associated with hepatitis B virus infection over a 12-year period, 1974 to 1985. All 13 patients were Yupik Eskimos and resided in southwest Alaska, an area hyperendemic for hepatitis B virus infection. The annual incidence of hepatitis B virus-associated polyarteritis nodosa for this population is 7.7 cases per 100,000 population. All patients presented with multisystem disease, and all had biopsy or angiographic findings consistent with polyarteritis nodosa. All 13 were positive for hepatitis B surface antigen and hepatitis B e antigen at diagnosis. Two untreated patients and two of five patients who received corticosteroids died, vs. none of six who received corticosteroids plus cyclophosphamide. None of the patients who survived the initial bout of polyarteritis nodosa has relapsed after a mean follow-up of 55 months, but all have become chronic HBsAg carriers. In eight patients, clinical or serologic evidence indicated that polyarteritis nodosa followed recent hepatitis B virus infection. We concluded that hepatitis B virus-associated polyarteritis nodosa is a serious, life-threatening complication that occurs early in the course of hepatitis B virus infection, is ameliorated by immunosuppressive therapy and can be prevented by hepatitis B vaccine.

Fate of the patient with chronic leg ischaemia. A review article

Much has been published on the surgical treatment of leg ischaemia but relatively little is known about the incidence of claudication and the fate of the majority of patients presenting with chronic leg ischaemia who never come to surgery. A review of the available literature suggests the following conclusions: (1) about 1.5% of men under 49 and 5% of men over 50 will develop symptoms of intermittent claudication. The incidence of asymptomatic arterial disease is much higher; (2) the incidence of claudication in women is only slightly less, but the local disease follows a more benign course; (3) compared to the general population of comparable age the mortality of men presenting with chronic leg ischaemia is two to three times higher after 5 years; (4) about 50% of deaths will be due to myocardial ischaemia, 15% to stroke and 10% to vascular disease in the abdomen. In only 25% will the principal cause of death be unconnected with the circulation; (5) there is virtually no reliable information available at the moment on the incidence of non-fatal myocardial infarction or stroke in these patients.

Centaur: the system

This paper describes the organization of the CENTAUR system and its main components. The system is a generic interactive environment. When given the formal specification of a particular programming language-including syntax and semantics — it produces a language specific environment. This resulting environment includes a structure editor, an interpreter/debugger and other tools, all of which have graphic interfaces. CENTAUR is made of three parts: a database component, that provides standardized representation and access to formal objects and their persistent storage; a logical engine that is used to execute formal specifications; an object-oriented man-machine interface that gives easy access to the system's functions. CENTAUR is essentially written in Lisp (Le_Lisp). The logical engine is Prolog (Mu-Prolog). The man-machine interface is built on top of the virtual graphics facility of Le_Lisp, itself primarily implemented on top of X-Windows.

Diuretics--a risk in the long-term treatment of hypertensive patients?

The trial of the European Working Party on High blood pressure in the Elderly (EWPHE) revealed an overall decrease in cardiovascular mortality and morbidity in the actively treated patients. They received as first-line drugs a combination of hydrochlorothiazide and triamterene; methyldopa was added as necessary. The present post hoc analysis examined the effect of the diuretic treatment on cardiovascular events, both when given alone and in conjunction with methyldopa, by calculating the relative hazard rates (RHR) for cardiovascular mortality and morbidity. Using the Cox proportional hazard model, compared with placebo, a 34% reduction in cardiovascular mortality in the intention-to-treat analysis was demonstrated in the diuretic (hydrochlorothiazide and triamterene) group with an RHR of 0.66 and a 95% confidence interval (CI) of 0.44-0.97; the 16% decrease in the group treated with diuretics and methyldopa was not significant (RHR, 0.84; 95% CI, 0.56-1.25). The effect of treatment in the latter combined group became significant (RHR, 0.62; 95% CI, 0.40-0.95) when all cardiovascular study terminating events were considered; they were reduced by 38%. No effect of treatment on mortality from all causes was detected.

Bromocriptine in an injectable retard form for puerperal lactation suppression: comparison with Estandron prolongatum

Intramuscular injection of a single 50-mg dose of long-acting bromocriptine microspheres was compared with a single intramuscular dose of an estradiol/testosterone ester combination in a single-blind, randomized study of 54 subjects. Bromocriptine was significantly more effective than the steroid drug in preventing milk flow, and rebound lactation was not observed in any bromocriptine-treated patients. Neither group showed deleterious side effects or significant biologic changes in coagulation parameters. There were no blood pressure or electrocardiographic alterations. Postpartum prolactin suppression was more intense after bromocriptine administration than after steroid therapy.

Acute oligohydramnios in postdate pregnancy

The evaluation of amniotic fluid volume plays a major role in antepartum fetal surveillance. Although the definition of diminished amniotic fluid volume varies, this sign is considered by itself an indication for intervention in the near-term fetus. The interval of testing is predicated on the concept that amniotic fluid volume diminishes slowly (unquantified) as a result of developing hypoxia. We present six postterm pregnancies in which amniotic fluid volume diminished abruptly over 24 hours. Although one fetus died, the three babies delivered by cesarean section and the two babies delivered after a 2-day labor did well, despite obvious postmaturity syndrome, meconium staining, and variable decelerations. Apgar scores in the survivors were above 8, and pH results failed to confirm hypoxia. These data suggest the need to better understand the mechanisms regulating amniotic fluid volume.

Restrictive cardiomyopathy caused by adipositas cordis

Adipositas cordis is a very rare disorder, characterized by fatty infiltration of myofibers. It has been related to dilated or hypertrophic cardiomyopathy and obesity. In this report, however, we present a non-obese patient, presenting with a restrictive syndrome and showing massive infiltration of adipocytes in the interventricular septum, proving adipositas cordis.

Absolute reflectometer for the 0.8-2.5-microm region

A reflectometer based on an integrating sphere operating in the 0.8-2.5-microm region is described. The reflectometer is of the absolute type and does not need a standard diffuse reflecting surface to obtain absolute reflectance values. The system is fully automatic, using computer-controlled circular variable filters as monochromators. Results for BaSO(4) in the region between the visible and 2.5 microm show considerable deviations from the accepted values of reflectivity for this substance.

Chyle: a masquerading etiology of pericardial effusion

A 25-year-old man with massive pericardial effusion is presented. The high lymphocyte amount and cytological analysis of the aspirated fluid suggested tuberculous or malignant pericarditis. The chylous nature of the effusion was only recognized after hemipericardiectomy, when reaccumulation of fluid into the pleural space appeared. This was successfully managed by medium chain triglyceride diet.

Influence of antihypertensive drug treatment on morbidity and mortality in patients over the age of 60 years. European Working Party on High blood pressure in the Elderly (EWPHE) results: sub-group analysis on entry stratification

The European Working Party on High blood pressure in the Elderly (EWPHE) trial was a double-blind randomized placebo-controlled trial of antihypertensive treatment in patients over the age of 60 years. Entry criteria included both a sitting diastolic blood pressure on placebo treatment in the range of 90-119 mmHg and a systolic blood pressure in the range of 160-239 mmHg. Eight-hundred and forty patients were randomly assigned either to active treatment (hydrochlorothiazide + triamterene) or a matching placebo. If blood pressure remained elevated methyldopa was added to the active regimen and matching placebo to the placebo regimen. Before randomization, the patients were stratified in eight strata according to sex, age groups between 60 and 69 years or 70 years and over, and the presence or absence of cardiovascular complications of hypertension. Both the intention-to-treat and 'on randomized treatment' analyses suggested a benefit from active treatment in men and women. Formal statistical significance was achieved for male cardiovascular mortality (intention-to-treat analyses) and for cardiovascular events in females. Although the event rates were greater for patients with previous cardiovascular events and patients over the age of 70 years, the percentage reduction in cardiovascular events was similar in these groups to those without complications and in patients between 60 and 69 years of age. However, little benefit from treatment could be demonstrated in patients over the age of 80 years. The presence or absence of smoking had no influence on response to treatment in these elderly patients.

Postoperative immunological response against contractile proteins after coronary bypass surgery

The pathogenesis of post-cardiac injury syndrome was studied prospectively in 62 patients who underwent coronary bypass grafting. Preoperative and serial postoperative titres of actin and myosin antibodies were measured by an enzyme linked immunosorbent assay. Perioperative cumulative release of serum aspartate and alanine aminotransferases, lactate dehydrogenase, and creatine kinase was calculated by approximation formulas that are used to estimate infarct size. Complete post-cardiac injury syndrome developed in eight (13%) patients and an incomplete syndrome developed in 16 (26%). There was a significant correlation between frequency and intensity of the syndrome and the ratio of postoperative to preoperative titres of actin and myosin antibodies. Furthermore, there was a significant correlation between the cumulative release of lactate dehydrogenase, serum aspartate aminotransferase, and creatine kinase and the number of coronary vessels that were grafted, but no correlation was found between the incidence of post-cardiac injury syndrome and the number of coronary bypasses grafted or between the cumulative enzyme release and the postoperative immunological response against the major contractile proteins, actin and myosin. The amount of enzymes released during coronary bypass surgery seems to be a good indicator of the extent of myocardial damage during operation but it does not determine either the incidence of post-cardiac injury syndrome or the postoperative immunological response against the main contractile proteins actin and myosin.

Glucose intolerance during diuretic therapy in elderly hypertensive patients. A second report from the European Working Party on high blood pressure in the elderly (EWPHE)

Five hundred and seven elderly hypertensive patients were followed for 1 year, 371 for 2 years and 270 for 3 years in a double-blind, randomized, controlled trial in which they received either placebo or 25-50 mg hydrochlorothiazide and 50-100 mg of triamterene daily. One third of the active treatment group also received 250 mg to 2 g methyldopa daily. After 1 year the active treatment group had an average increase in fasting blood sugar of 2.5 mg/dl compared with an average fall of 1.4 mg/dl in the placebo group (P = 0.01). The increase in blood sugar 1 hour and 2 hours after 50 g oral glucose tended to be greater in the actively treated group but these increases did not achieve statistical significance. The effects of diuretic treatment were established after one year and did not increase further over the next 2 years. Overall there was an increase in fasting blood sugar of 5 mg/dl in the active treatment group which occurred mainly in the first year. The hyperglycaemic effect of diuretics appeared to be partly or wholly related to potassium loss since, in both groups, impairment of glucose tolerance was most marked in those in whom serum potassium decreased. The measures of blood sugar were also positively related to systolic pressure before and after treatment.

Efficacy of antihypertensive drug treatment according to age, sex, blood pressure, and previous cardiovascular disease in patients over the age of 60

Results of the European Working Party on High Blood Pressure in the Elderly (EWPHE) trial have been analysed in relation to age, sex, blood pressure, and previous cardiovascular disease. Cardiovascular mortality and the cardiovascular study-terminating events were significantly and independently related to treatment, age, cardiovascular complications at randomisation, and systolic but not diastolic blood pressure. The benefits of treatment observed in the trial seemed to be independent of entry blood pressure and the presence or absence of cardiovascular complications at entry. There was some evidence that treatment effect decreases with advancing age. Little or no benefit from treatment could be demonstrated in patients over the age of 80 years, the great majority of whom were women.