Treatment of streptococcal endocarditis with a single daily dose of ceftriaxone sodium for 4 weeks. Efficacy and outpatient treatment feasibility

OBJECTIVE--To evaluate the efficacy and safety of ceftriaxone sodium in the treatment of streptococcal endocarditis. DESIGN--An open, multicenter, noncomparative study with a follow-up of patients for 4 months to 5 years. SETTING--Internal medicine wards and outpatient clinics of hospitals of various sizes in three European countries. PATIENTS--Fifty-nine patients with defined criteria for streptococcal endocarditis. INTERVENTION--Ceftriaxone sodium administered at a once-daily dose of 2 g for 4 weeks. MAIN OUTCOME MEASURES--Clinical outcome and microbiological cure rate. RESULTS--Among the 59 patients, 55 completed the treatment and were followed up for 4 months to 5 years. No patients showed evidence of relapse. Treatment was completely uneventful in 42 patients (71%). A cardiac valve was replaced in four patients (7%) receiving antimicrobial therapy and in six patients (10%) who had completed antimicrobial therapy. One of the 10 valves taken for culture at surgery was positive, but only for microorganisms that were different from the microorganism isolated before the treatment. The treatment had to be interrupted in four patients because of drug allergy. Other side effects were mild except for two cases of reversible neutropenia. The treatment was easy to administer: 27 patients (46%) had no permanent intravenous catheter at any time, seven patients (12%) had such a catheter for less than 4 days. Twenty-three patients (39%) were discharged from the hospital less than 2 weeks after admission.

CONCLUSIONS

--Ceftriaxone sodium administered at a once-daily dose of 2 g appears to be an effective and safe treatment of streptococcal endocarditis. In hospitals, this agent may be more convenient to administer than penicillin G with or without aminoglycosides. Some patients may even be treated as outpatients.

[The treatment of heart insufficiency in coronary heart disease]

In acute as well as in chronic ischemic heart disease, congestive heart failure indicates a poor prognosis. Treatment after acute myocardial infarction should differentiate between specific subsets. In cardiogenic shock due to extensive ischemic damage, acute revascularization by PTCA or CABG improves the otherwise poor outcome substantially. In congestive heart failure, pre- and afterload reduction by nitrates should be combined with dopamine if systolic blood pressure is below 100 mmHG or dobutamine if an inotropic substance is necessary despite systolic blood pressure greater than 100 mmHg. Amrinone is a potent alternative which combines positive inotropic and vasodilating properties. In chronic ischemic heart disease, congestive heart failure is a clearly defined indication for complete revascularization, if possible. As to drug treatment, progression of the disease characterized by a cardiomyopathy of overload as well as neurohormonal and peripheral maladaptation should be stopped in parallel with symptom relief. Therefore, ACE-Inhibitors are combined very early with diuretic treatment, and digitalis should be added in refractory patients.

Colour coded duplex sonography in suspected deep vein thrombosis of the leg

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Severe neonatal asphyxia due to X-linked centronuclear myopathy

Severe neonatal centronuclear myopathy is inherited as an X-linked condition characterized by primary asphyxia, extreme muscular hypotonia and absent spontaneous movements. We report seven cases from three families to point out the importance of diagnosis with regard to prognosis, outcome and genetic counselling. In hypotonic diseases, analysis of cerebrospinal fluid, electromyography, nerve conduction velocity creatine kinase and a skin biopsy for fibroblast cultures for metabolic investigations are usually carried out. Needle muscle biopsy is an additional valuable investigation to establish diagnosis. In all our patients we found an increased number of centrally located nuclei with perinuclear halos confirming the diagnosis of centronuclear myopathy. The diagnosis of this disorder will become of greater importance as soon as carrier detection and prenatal diagnosis by DNA-technology are routinely available.

Passive smoking and 20-year cardiovascular disease mortality among nonsmoking wives, Evans County, Georgia

The association of passive smoking and cardiovascular disease (CVD) mortality was assessed in a cohort of 513 rural, married Black and White women who were disease-free and self-described as never-smokers at baseline in 1960. Over a 20-year period, 76 of 147 total deaths were attributed to CVD. Relative risk estimates adjusted for age, cholesterol, blood pressure, and body mass from proportional hazards models were 1.59 for CVD (95% CI = 0.99, 2.57) and 1.39 (CI = 0.99, 1.94) for all cause mortality among women with husbands who smoked cigarettes.

X linked neonatal centronuclear/myotubular myopathy: evidence for linkage to Xq28 DNA marker loci

We have studied the inheritance of several polymorphic Xq27/28 DNA marker loci in two three generation families with the X linked neonatal lethal form of centronuclear/myotubular myopathy (XL MTM). We found complete linkage of XLMTM to all four informative Xq28 markers analysed, with GCP/RCP (Z = 3.876, theta = 0.00), with DXS15 (Z = 3.737, theta = 0.00), with DXS52 (Z = 2.709, theta = 0.00), and with F8C (Z = 1.020, theta = 0.00). In the absence of any observable recombination, we are unable to sublocalise the XLMTM locus further within the Xq28 region. This evidence for an Xq28 localisation may allow us to carry out useful genetic counselling within such families.

[Prevention of hyaline membrane disease]

Prevention of respiratory distress syndrome (RDS) may be achieved with measures aimed at lung maturation and at prevention of perinatal asphyxia. Besides successful inhibition of premature labor, the following substances have clinical importance in lung maturation: glucocorticosteroids, thyroid hormones, aminophylline and ambroxol. The efficacy of prenatal steroids has been demonstrated in numerous studies. Most of the potential risks in this treatment have not shown any relevance in clinical trials. Prenatal steroids are so far the standard approach to lung maturation. Certain contraindications and limitations need to be taken into consideration. The results with thyroid hormones are still limited and also contradictory. When steroids are contraindicated, they may still be of possible value. Aminophylline was found to be just as efficacious as steroids, with fewer infectious complications. These studies are, however, limited in number. Ambroxol was found to improve lung maturation after the 32nd week of gestation in a few studies. It seems to have few side effects. Possibly, it will also prove to be effective in treating established RDS.

Body sodium/blood volume state in normotensive members of normotensive and hypertensive families

Exchangeable sodium is lower than normal in young male patients with essential hypertension. This may reflect a primary abnormality of sodium metabolism, or natriuresis caused by sodium-independent elevation of arterial pressure. To investigate this question, 31 normotensive men with positive and 31 normotensive men with negative family history of essential hypertension were studied. Blood pressure tended to be higher in the former (121/78 +/- 9/8 (s.d.) versus 113/74 +/- 11/9 mmHg; P less than 0.005); mean age, urinary sodium or potassium excretion, plasma sodium, potassium, renin activity or aldosterone levels and creatinine clearance were comparable. Exchangeable sodium and blood volume were also similar in the two groups, when expressed in absolute values (3113 +/- 306 versus 3044 +/- 242 mmol and 4902 +/- 581 versus 4769 +/- 579 ml, respectively) or in relation to body surface area (100.8 +/- 7.1 versus 100.2 +/- 6% and 103.8 +/- 12.2 versus 102 +/- 11.3%). In both groups, exchangeable sodium and blood volume were unrelated to arterial pressure. The body sodium/blood volume state is normal in normotensive subjects with positive family history. The low exchangeable sodium of young patients with essential hypertension does not appear to reflect a primary familial abnormality of body sodium metabolism.