N-terminal pro-B-type natriuretic peptide for prediction of ventricular arrhythmias: Data from the SMASH study

BACKGROUND

Elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations predict heart failure (HF) and mortality, but whether NT-proBNP predicts ventricular arrhythmias (VA) is not clear.

HYPOTHESIS

We hypothesize that high NT-proBNP concentrations associate with the risk of incident VA, defined as adjudicated ventricular fibrillation or sustained ventricular tachycardia.

METHODS

In a prospective, observational study of patients treated with implantable cardioverter defibrillator (ICD), we analyzed NT-proBNP concentrations at baseline and after mean 1.4 years in association to incident VA.

RESULTS

We included 490 patients (age 66 ± 12 years, 83% men) out of whom 51% had a primary prevention ICD indication. The median NT-proBNP concentration was 567 (25-75 percentile 203-1480) ng/L and patients with higher concentrations were older with more HF and ICD for primary prevention. During mean 3.1 ± 0.7 years, 137 patients (28%) had ≥1 VA. Baseline NT-proBNP concentrations were associated with the risk of incident VA (hazard ratio [HR]: 1.39, 95% confidence interval [95% CI]: 1.22-1.58, p < .001), HF hospitalizations (HR: 3.11, 95% CI: 2.53-3.82, p < .001), and all-cause mortality (HR: 2.49, 95% CI: 2.04-3.03, p < .001), which persisted after adjusting for age, sex, body mass index, coronary artery disease, HF, renal function, and left ventricular ejection fraction. The association with VA was stronger in secondary versus primary prevention ICD indication: HR: 1.59 (95% CI: 1.34-1.88 C-statistics 0.71) versus HR: 1.24, 95% CI: 1.02-1.51, C-statistics 0.55), p-for-interaction = 0.06. Changes in NT-proBNP during the first 1.4 years did not associate with subsequent VA.

CONCLUSIONS

NT-proBNP concentrations are associated with the risk of incident VA after adjustment for established risk factors, with the strongest association in patients with a secondary prevention ICD indication.

Biomarkers associated with vulnerable plaques

Background

Cardiovascular heart disease is the leading cause of mortality worldwide, with the rupture or thrombosis of an atherosclerotic plaque being the main reason behind an acute coronary syndrome. It has already been established that the morphology of atherosclerotic plaques determine their stability. A lipid rich lesion with a thin fibrous cap is more prone to rupture compared to solid fibrous lesions. In the PROSPECTII study we used Near infrared spectroscopy (NIRS) and Intravascular ultrasound (IVUS) to identify atherosclerotic plaques in the coronary arteries; NIRS-derived lipid core burden index (LCBI) and IVUS-derived plaque burden (PB) identified plaques that caused adverse cardiovascular events.

Purpose

Our aim is to find biomarkers associated with LCBI or PB, to understand the development of vulnerable plaques.

Methods

902 patients were enrolled in this study after successful percutaneous coronary intervention (PCI). A combined NIRS-IVUS catheter was then used to analyze approximately 200m of coronary arteries. Blood samples for biomarker analysis were taken before the PCI procedure and plasma levels of 182 proteins associated with cardiovascular disease were assessed using a novel method for measuring proximity extension assay. Adjusted linear regression models were calculated between the biomarkers and the outcomes of interest, followed by a false discovery rate (FDR) correction.

Results

We found 24 proteins associated with plaque burden and 28 proteins associated with LCBI after using a cut off of two tailed P value &lt;0.05. An overlap of 8 biomarkers could be seen between the two groups. After adjusting the P values with FDR, Angiopoeitin like 3 (ANGPTL3) retained its association to LCBI, and Interleukin 18 receptor 1 (IL18R1) and colony stimulating factor 1 (CSF-1) to plaque burden.

Conclusion

We were able to identify different biomarker patterns associated with plaque burden compared to lipid rich vulnerable plaques. ANGPTL3 was shown to only have an association with lipid rich plaques and not with solid fibrous lesions which further supports its role in vulnerable plaques.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott Vascular, Infraredx, and The Medicines Company

Validation of a novel high-sensitivity cardiac troponin assay

Background

The accuracy for early identification of non-ST-elevation myocardial infarction (NSTEMI) in the emergency department must be determined for all novel high-sensitivity cardiac troponin assays (hs-cTn). In this prospective, multi-centre study we developed rule-out algorithms for a high-sensitivity cardiac troponin I (hs-cTnI) assay and compared it to established algorithms for hs-cTnT and hs-cTnI.

Methods

Two rule-out algorithms for NSTEMI were developed from a derivation cohort of 977 patients assessed by the Siemens Atellica IM hs-cTnI assay. Diagnostic performance was compared with hs-cTnT (Roche) and hs-cTnI (Abbott) algorithms. The derived algorithms were tested in two different validation cohorts (n=518 and n=405, respectively).

Results

An admission sample algorithm (hs-cTnI (Siemens)) for rule-out of NSTEMI with cutoff &lt;5 ng/L had negative predictive value (NPV) 99.4–100.0%, sensitivity 98.3–100% and specificity 46.7–56.5% in the two validation cohorts. Sensitivity and NPV was similar, specificity trended towards improvement over the comparator algorithms (Figure 1).

A 0–1 hour algorithm (hs-cTnI (Siemens)) with cutoff &lt;10 ng/L and Δ change &lt;3 ng/L achieved sensitivity and NPV 100% with specificity &gt;70% in both validation cohorts, similar to the comparator algorithms (Table 1).

Conclusions

Rule-out algorithms from the Siemens Atellica hs-cTnI assay has comparable diagnostic accuracy to established hs-cTn rule-out algorithms.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Public grant: Western Norway Regional Health Authority.Private company funding: Siemens Healthineers AG

Phenotyping patient-reported health profiles in octogenarians with coronary artery disease – a latent profile analysis

Background

Percutaneous coronary intervention (PCI) has demonstrated to be an effective treatment strategy also in octogenarian patients (≥80 years). However, limited studies describe patient-reported outcomes in older adults two months after the PCI procedure.

Purpose

To identify latent health profiles concerning fatigue, generic and disease-specific physical and mental health, anxiety and depression, insecurity, dependency and angina frequency. Further, to investigate if these profiles were associated with sex or cohabitation status.

Method

A prospective cohort multicenter study including 3417 patients was conducted. The following patient-reported outcome measures were used: Level of fatigue was assessed using de novo created questions. Generic physical and mental health was assessed using RAND-12. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale. Disease-specific physical and mental health status, insecurity and dependency were assessed with Myocardial Infarction Dimensional Assessment Scale, and disease-specific physical limitation, quality of life and angina frequency was assessed with Seattle Angina Questionnaire (SAQ-7). All scales were converted to a 0–100 scale (worst to best). Latent profile analysis was used for phenotyping health profiles and multinomial logistic regression analysis for investigating the association of sex and cohabitation status across health profiles.

Result

A total of 318 octogenarians were included. The mean age was 83.6 years, and 69% were males. Three health profiles differing in the level of fatigue, health status, insecurity and dependency and angina frequency were identified (Figure 1). Health profile 1 (26.1%) represents “Low-level of life satisfaction, high level of insecurity and dependency and monthly frequency of angina”. Health profile 2 (38.1%) represents “Medium-level of life satisfaction, medium-level of insecurity and dependency and monthly frequency of angina”. Health profile 3 (35.8%) represents “High-level of life satisfaction, low level of insecurity and dependency and angina free”. Importantly, female sex was strongly associated with being classified into Health profile 1 compared to Health profile 3 [OR 3.6, 95% CI 1.3–7.9]. Living alone however, did not predict a likelihood of being classified into any particular health profile.

Conclusion

We identified three unique health profiles of octogenarians with coronary artery disease. A quarter of the participants were classified into the “Low-level of life satisfaction” profile. In addition, female sex was strongly associated with being identified into the “Low-level of life satisfaction” profile. These result suggest a need for a more tailored and patient-centered aftercare in octogenarians undergoing PCI.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): MTG Holding AS

Informing patients about potential adverse drug reactions after percutaneous coronary intervention reduces the occurrence of self-reported adverse drug reactions

Background

Healthcare providers are commonly reluctant to inform patients about potential adverse drug reactions (ADRs) from prescribed therapy to avoid increasing the incidence of ADRs through the nocebo effect. However, patients need information on all aspects of prescribed therapy to facilitate informed decision-making and take ownership of their care.

Purpose

To describe wether patients received information about potential ADRs from prescribed therapy before hospital discharge after percutaneous coronary intervention (PCI). Furthermore, to determine whether receiving information about ADRs is associated with incidence of self-reported ADRs.

Methods

CONCARDPCI is a prospective multicentre cohort study including 3417 patients after PCI. The study was conducted between June 2017 and May 2020 at seven large referral PCI centres in Norway and Denmark. Clinical data were collected from patients' medical records. Socio-demographic characteristics were obtained by self-report during index hospitalization after PCI. Two questions from the Heart Continuity of Care Questionnaire were used to determine if information about potential ADRs was received before hospital discharge. De novo created questions were used to determine if patients reported ADRs from prescribed therapy. Questionnaires were distributed two (T1), six (T2), and twelve months (T3) after hospital discharge to assess the incidence of self-reported ADRs in a longitudinal perspective. Logistic regression was utilised to scrutinize the aims, reported as odds ratios (ORs) with 95% confidence intervals (CIs).

Results

Patients were predominantly men (78%), with a mean age of 66 years (SD 11, range 20–96 years), and married or living with a partner (75%). Stable coronary artery disease was the most frequent cause of admission for PCI (30%). Before hospital discharge, 59% were informed of potential ADRs from prescribed therapy and 50% were informed what to do if ADRs occurred. The incidence of self-reported ADRs were significantly lower for those who were informed of potential ADRs compared to those who were not informed at T1 (OR 0.54, CI: 0.45–0.65, p&lt;0.001), T2 (OR 0.56, CI: 0.46–0.70, p&lt;0.001) and T3 (OR 0.51, CI: 0.42–0.67, p&lt;0.001) (Figure 1). After controlling for socio-demographic and clinical variables, the incidence of self-reported ADRs were similar at T1 (OR 0.58, CI: 0.47–0.71, p&lt;0.001), T2 (OR 0.56, CI: 0.46–0.70, p&lt;0.001) and T3 (OR 0.53, CI: 0.42–0.66, p&lt;0.001). Those less likely to receive information about ADRs were living alone (OR 0.75, CI: 0.59–0.97; p=0.029), women (OR 0.58, CI: 0.45–0.75, p&lt;0.001) and those with three or more comorbidities (OR 0.68, CI: 0.47–0.98, p=0.029) compared to their counterparts.

Conclusion

Our study showed that informing patients about potential ADRs after PCI reduces the occurrence of self-reported ADRs. Information about potential ADRs should be provided regardless of cohabitation status, sex and comorbidities.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Western Norway Health Authority

Health literacy and physical and mental health status in octogenarian patients with coronary artery disease - a prospective cohort multicentre study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): MTG Holding AS

Introduction

The number of octogenarians (≥80 years of age) receiving percutaneous coronary intervention (PCI) is rising. Evidence supports that PCI improves quality of life and functional status in this group. Optimal health-promoting behaviour is strongly influenced by health literacy. However, there is limited knowledge about the association between health literacy, physical and mental health status in octogenarians.

Purpose

To determine if octogenarians health literacy is associated with generic and disease-specific physical and mental health status after PCI.

Methods

A prospective cohort study recruited 3417 participants from seven Danish and Norwegian PCI centres, and was conducted from June 2017 until May 2019. Multiple linear regression analysis was used. Health literacy was assessed by four of the nine scales from the Health Literacy Questionnaire (HLQ) (were higher score are better); "Social support for health" (scale range 1-4) "Appraisal of health information", (scale range 1-4) "Ability to find good health information" (scale range 1-5) and "Understand health information well enough to know what to do" (scale range 1-5). Generic physical and mental health status was assessed with RAND-12 at baseline (scale range 0-100, were higher score are better). After two months, disease-specific physical and mental health status was assessed with Myocardial Infarction Dimensional Assessment Scale (scale range 0-100, were lower score are better). Socio-demographic (age, gender, cohabitation status, education) and clinical variables (number of comorbidities) were included as covariates.

Results

In all, 318 octogenarians with mean age 83.4 years (range 80-96) participated, of which 69% were males. Three aspects of health literacy, "Social support for health", "Ability to find good health information" and "Understand health information well enough to know what to do", were significantly associated with health status. Specifically, for a unit increase of "Social support for health", the generic mental health status increased by 3 units (B: 3.0 [0.2 to 5.8] P=0.034). Further, a unit increase of "Ability to find good health information" was associated with a significant 4.2 higher disease-specific physical health and significant 5.3 higher disease-specific mental health (B:-4.2 [-8.0 to -0.4] P=0.029, B:-5.3 [-9.0 to -1.6] P=0.005, respectively). Finally, for a unit increase of "Understand health information well enough to know what to do" the disease-specific physical health improved by 5.1 units (B:-5.1 [-9.7 to -0.5] P=0.029) and disease-specific mental health improved by 5.2 units (B:-5.2 [-9.7 to -0.7] P=0.025).

Conclusion

In this study, we found that elements of health literacy were associated with both physical and mental health status in octogenerians. These findings highlight the importance of adequate health literacy and the need to support those with lower health literacy following PCI.

Reduced LVEDD following a 12 week exercise training program in patients with symptomatic chronic heart failure is associated with reduction in serum levels of Troponin I

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Norwegian University of Science and Technology Danish Research Council

Background

Exercise training (ET) exerts many beneficial effects on the cardiovascular system, and longitudinal observational data from epidemiological studies suggest that higher physical activity is associated with lower concentrations of cardiac troponins. We have previously shown that ET can reduce Left Ventricle End-diastolic diameter (LVEDD), and improve exercise capacity.

Purpose

Our aim was to explore the relationship between changes in LVEDD and changes in high-sensitive plasma troponin I (hs-TnI) levels in patients with symptomatic heart failure undergoing a 12 week structured exercise training program in the randomized multicenter SMARTEX trial.

Methods

This was a post hoc analysis in 199 patients with symptomatic HF with LVEF &lt;35% and NYHA II-III that were randomly assigned to High Intensity Interval Training (HIIT, n = 73), Moderate Continuous Training (MCT, n = 59) or Recommendation of Regular Exercise, (RRT, n = 67) for 12 weeks. Log-transformed Hs-TnI measurements and clinical data acquired before (BL) and after a 12 week exercise training intervention (12 weeks) and at 1 year follow-up (1 year) were analysed using a linear mixed model. For Troponin analysis the STAT Troponin-I from Abbott Diagnostics was used.

Nakagawa’s marginal R2 and conditional R2 were used to evaluate variance explained by fixed effects only and by fixed and random effects together, respectively.

Changes of LVEDD between baseline and 12 weeks and baseline and 52 weeks were evaluated using linear mixed model. The outcome variable were measures of LVEDD, while age, sex, visit and training group and their interaction [visit × training group]  were included as fixed effects. Patient id and training center were random effects. Covariance structure was compound symmetry.

Linear association between log-transformed TnI and LVEDD baseline was evaluated using Pearson correlation coefficient (R).

Results

Serum was available for hs-TnI analyses in 199 patients. In the HIIT group there was a sustained significant reduction in LVEDD at both 12 and 52 weeks.

In the MCT group this reduction was statistically significant at 52 weeks only.

Mixed model analysis predicts that each 1 mm decrease in LVEDD is associated with 1.2% decrease in TnI levels (95% CI: 0.6 – 1.9%, p &lt;0.001). Neither time nor training group were associated with changes of TnI (overall test p = 0.739 and p = 0.987, respectively).

Dynamics of TnI is highly patient-specific with Intraclass correlation coefficient (ICC) = 0.86. Mixed model explains 87% variation of the data (conditional R2), however, only 7% is attributed to the fixed effects (marginal R2).

At baseline, TnI and LVEDD have modest but statistically significant correlation (R = 0.2, p= 0.004).

Conclusions

A reduction of LVEDD following a 12-week exercise-training program is associated with a reduction in plasma troponin levels, in patients with mild to moderate chronic heart failure. Abstract Figure.

Perceptions of efficacy and safety of generic medicines in patients after percutaneous coronary intervention

Background

Generic medicines are bioequivalents to brand-name medicines, and compelling evidence for the safety and efficacy of generic medicines exists. However, negative perceptions about generic medicines can potentially reduce adherence to prescribed therapy and thereby efficacy of the treatment.

Purpose

To describe patients' perceptions of generic medicines after percutaneous coronary intervention (PCI), and to investigate the association between perceptions and sociodemographic and clinical factors. Furthermore, we sought to investigate if these perceptions change over time.

Methods

CONCARDPCI is a large-scale prospective multicentre cohort study on 3251 patients after PCI. The study was conducted between June 2017 and May 2020 at seven large referral PCI centres in Norway and Denmark. Clinical data, including invasive procedures and patient characteristics, were collected from the patients' medical records. Sociodemographic characteristics were obtained by self-report during index hospitalization after PCI. Postal or electronic questionnaires comprising questions regarding perceptions of generic medicines were distributed two (T1) and six (T2) months after discharge from hospital to included patients. The time intervals ensured that a sufficient amount of time had passed so that refill of prescriptions was necessary. To investigate perceptions of generic medicines and the associations with sociodemographic and clinical characteristics, logistic regression analysis was performed.

Results

Most patients were men (78%), married or living with a partner (75%), elderly (mean age 66 years, SD11, range 20–96 years), and 28% were admitted to hospital due to non-ST-segment elevation myocardial infarction. At T1, 70% perceived generic medicines to be as effective, safe (68%), produce the same side effects (64%), and contain the same active ingredients as brand-name medicines (64%). Perceptions of generic medicines were similar at T2. No significant associations were found with age, marital status, living alone, taking ≥5 medications, or participation in cardiac rehabilitation. However, Danish patients (p&lt;0.001), those with a higher education level (college/university≥4 years) (p=0.01), total household income &gt;83,000 Euro (p=0.007), female gender (p&lt;0.001), and history of coronary artery disease (p=0.048) had more positive perceptions of generic medicines.

Conclusion

Approximately one third of the patients had negative perceptions of generic medicines after PCI, and these negative perceptions do not seem to change substantially during the first six months after PCI. As negative perceptions of generic medicines have been found to be a barrier to medication adherence, improving patients' knowledge and confidence in generic medicines after PCI may be pivotal to reach treatment goals set forth by the 2018 ESC/EACTS Guidelines on myocardial revascularization.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The Western Norway Health Authority

Rationale and design of the PRevention of cArdiac Dysfunction during Adjuvant breast cancer therapy (PRADA II) trial: a randomized, placebo-controlled, multicenter trial

Background

Recent advances in the treatment algorithms of early breast cancer have markedly improved overall survival. However, anthracycline- and trastuzumab-associated cardiotoxicity may lead to dose-reduction or halt in potentially life-saving adjuvant cancer therapy. Early initiated neurohormonal blockade may prevent or attenuate the cardiotoxicity-induced reduction in cardiac function, but prior studies have been inconclusive. The angiotensin receptor-neprilysin inhibitor sacubitril/valsartan has been shown to be superior to traditional treatment in heart failure with reduced ejection fraction, but its cardioprotective effects in the cardio-oncology setting remains to be tested.

Objective

To assess if sacubitril/valsartan given concomitantly with early breast cancer treatment regimens including anthracyclines, with or without trastuzumab, may prevent cardiac dysfunction.

Methods

PRADA II is a randomized, placebo-controlled, double blind, multi-center, investigator-initiated clinical trial. Breast cancer patients from four university hospitals in Norway, scheduled to receive (neo-)adjuvant chemotherapy with epirubicin independently of additional trastuzumab/pertuzumab treatment, will be randomized 1:1 to sacubitril/valsartan or placebo. The target dose is 97/103 mg b.i.d. The patients will be examined with cardiovascular magnetic resonance (CMR), echocardiography, circulating cardiovascular biomarkers and functional testing at baseline, at end of anthracycline treatment and following 18 months after enrolment. The primary outcome measure of the PRADA II trial is the change in left ventricular ejection fraction (LVEF) by CMR from baseline to 18 months. Secondary outcomes include change in LV function by global longitudinal strain by CMR and echocardiography and change in circulating cardiac troponin concentrations.

Results

The study is ongoing. Results will be published when the study is completed.

Conclusion

PRADA II is the first randomized, placebo-controlled study of sacubitril/valsartan in a cardioprotective setting during (neo-)adjuvant breast cancer therapy. It may provide new insight in prevention of cardiotoxicity in patients receiving adjuvant or neo-adjuvant therapy containing anthracyclines. Furthermore, it may enable identification of patients at higher risk of developing cardiotoxicity and identification of those most likely to respond to cardioprotective therapy.

Trial registration

The trial is registered in the ClinicalTrials.gov registry (identifier NCT03760588). Registered 30 November 2018.

Pentraxin 3 in primary percutaneous coronary intervention for ST elevation myocardial infarction is associated with early irreversible myocardial damage : Kinetic profile, relationship to interleukin 6 and infarct size

Background

The inflammatory marker long pentraxin 3 (PTX3) has been shown to be a strong predictor of 30-day and one-year mortality after acute myocardial infarction. The aim of this study was to evaluate the kinetic profile of PTX3 and its relationship with interleukin 6 (IL-6), high-sensitive C-reactive protein (hs-CRP) and infarct size.

Methods

PTX3, IL-6 and hs-CRP were measured at predefined time points, at baseline (before percutaneous coronary intervention (PCI)), at 12 and 72 hours after PCI in 161 patients with first-time ST elevation myocardial infarction (STEMI).

Results

PTX3 and IL-6 levels increased in the early phase, followed by a gradual decrease between 12 and 72 hours. There were statistically significant correlations between PTX3 and IL-6 in general, for all time points and for changes over time (0–72 hours). In a linear mixed model, PTX3 predicted IL-6 (p < 0.001). PTX3 is also correlated with hs-CRP in general, and at each time point post PCI, except at baseline. PTX3, IL-6 and hs-CRP were all significantly correlated with infarct size in general, and at the peak time point for maximum troponin I. In addition, there was a modest correlation between IL-6 levels at baseline and infarct size at 72 hours after PCI (ρ = 0.23, p = 0.006).

Conclusions

PTX3 had a similar kinetic profile to IL-6, with an early increase and decline, and was statistically significantly correlated with markers of infarct size in STEMI patients post primary PCI. Baseline levels of IL-6 only predicted infarct size at 72 hours post PCI.

P1749Mortality in ST segment elevation myocardial infarction treated with primary percutaneous intervention in Norway A report from the Norwegian registry of invasive cardiology (NORIC)

Introduction

Limitations of the current reports on prognosis in ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI), are that they are based on selected samples from hospitals voluntary registries, trials and surveys and thereby lack full population coverage. In contrast to most developed countries, Sweden and the UK were for a long term, the only two countries worldwide that had continuous national clinical registries for acute coronary syndrome with mandated participation for all hospitals. This is now also the case in Norway. Of all STEMIs admitted to hospital in Norway, 77% is treated with PCI (2016). Since 2013 invasive coronary procedures is registered in The Norwegian registry for invasive cardiology (NORIC).

Purpose

The purpose of the current report from NORIC was to assess the mortality rates in patients treated with PCI for STEMI in Norway. Moreover we sought to assess the relationship between mortality and age at admission in this population.

Methods

NORIC, which is a part of the Norwegian Cardiovascular Disease Registry (NCDR), is a national person-identifiable health registry that does not require consent from the registered individual. Data were registered from 1st of January 2013 to 13th of June 2018.

Results

During this period 10524 patients were registered with a STEMI. The incidence is calculated for the years of 2015–2017 when the registry had full national coverage. The incidence of STEMI treated with PCI in Norway was (53 in 2015, 50 in 2016 and 52 in 2017 per 100 000). For patients younger than 80 years at admission, the mortality rates were 4.9%, 6.8% and 8.0% at 30 days, 365 days and 730 days respectively. For patients older than 80 years at admission the mortality rates were 8.3%, 15.6% and 19.0% at 30 days, 365 days and 730 days respectively. The mortality rates stratified by age are illustrated in figure 1.

Survival stratified by age

Conclusions

Mortality in STEMI patients offered primary PCI in Norway is equal or even lower than the mortality reported from well-established national registries from UK and Sweden. This indicates a well functioning treatment strategy despite challenging geography. Age is an important determinant of mortality.

P826Peri-procedural treatment with high dose Rosuvastatin reduces soluble TNF receptor 1 in patients treated with primary percutaneous coronary intervention for ST elevation myocardial infarction

Background

The extent of cardiac injury in ST elevation myocardial infarction (STEMI) depends on the level of inflammation and subsequent immune cell recruitment. An inflammatory phase that is disproportionately prolonged, of excessive magnitude, or insufficiently suppressed, can lead to sustained tissue damage and improper healing, promoting infarct expansion, adverse remodelling and chamber dilatation. Soluble TNF receptor 1 (sTNFR-1) is believed to mirror systemic pan-inflammatory status more closely than a single cytokine antigenic level. sTNFR-1 levels might give prognostic information, independent from and, at the same time, additive with some well-recognized outcome predictors such as left ventricular ejection fraction.

Purpose

We hypothesised that sTNFR-1 and other inflammatory markers could be modulated by statins.

Methods

Plasma levels of inflammatory markers were measured at baseline, 2 days, 7 days and 2 months in consecutive patients with first time STEMI with single vessel disease. Twenty-five patients (treatment group (TG)) were treated with 80 mg Rosuvastatin daily with first dose before primary percutaneous coronary intervention (PCI) whereas the control group (CG) consisted of 34 patients in whom treatment with 20 mg simvastatin daily were initiated the day after PPCI.

Results

sTNFR1 increased during the first 48 hours following PCI and this increase was larger in the CG compared with the TG (0.22±0.30 ng/mL vs 0.08±0.19 ng/nmL, p=0.025). The difference in increase during one week was only borderline statistically significant (0.21±0.30 ng/mL vs 0.08±0.26 ng/mL, p=0.081). These differences in the kinetics of sTNRF-1 were mirrored by changes in Pentraxin 3 (PTX3) between groups from baseline to 1 week, CG vs TG. (0.28±0.70 μmol/l vs 0.10±0.05 ng/mL, p=0.014) and at 2 months (−0.42±0.56 ng/mL vs 0.08±0.60 μmol/l, p=0.032)

Conclusion

High dose Rosuvastatin therapy initiated peri-procedural during PPCI for STEMI reduces pan inflammation as reflected by sTNFR1 and is associated with a less abrupt fall in PTX3 at 1 week and 2 months supporting recent research suggesting that PTX3 plays a cardiovascular protective effect in cardiovascular disease and healing.

Acknowledgement/Funding

Western Norway Regional Health Authority

Factors predicting the use of therapeutic hypothermia and survival in unconscious out-of-hospital cardiac arrest patients admitted to the ICU

INTRODUCTION

Therapeutic hypothermia (TH) after out-of-hospital cardiac arrest (OHCA) was adopted early in Norway. Since 2004 the general recommendation has been to cool all unconscious OHCA patients treated in the intensive care unit (ICU), but the decision to cool individual patients was left to the responsible physician. We assessed factors that were associated with use of TH and predicted survival.

METHOD

We conducted a retrospective observational study of prospectively collected cardiac arrest and ICU registry data from 2004 to 2008 at three university hospitals.

RESULTS

A total of 715 unconscious patients older than 18 years of age, who suffered OHCA of both cardiac and non-cardiac causes, were included. With an overall TH use of 70%, the survival to discharge was 42%, with 90% of the survivors having a favourable cerebral outcome. Known positive prognostic factors such as witnessed arrest, bystander cardio pulmonary resuscitation (CPR), shockable rhythm and cardiac origin were all positive predictors of TH use and survival. On the other side, increasing age predicted a lower utilisation of TH: Odds Ratio (OR), 0.96 (95% CI, 0.94 to 0.97); as well as a lower survival: OR 0.96 (95% CI, 0.94 to 0.97). Female gender was also associated with a lower use of TH: OR 0.65 (95% CI, 0.43 to 0.97); and a poorer survival: OR 0.57 (95% CI, 0.36 to 0.92). After correcting for other prognostic factors, use of TH remained an independent predictor of improved survival with OR 1.91 (95% CI 1.18-3.06; P <0.001). Analysing subgroups divided after initial rhythm, these effects remained unchanged for patients with shockable rhythm, but not for patients with non-shockable rhythm where use of TH and female gender lost their predictive value.

CONCLUSIONS

Although TH was used in the majority of unconscious OHCA patients admitted to the ICU, actual use varied significantly between subgroups. Increasing age predicted both a decreased utilisation of TH as well as lower survival. Further, in patients with a shockable rhythm female gender predicted both a lower use of TH and poorer survival. Our results indicate an underutilisation of TH in some subgroups. Hence, more research on factors affecting TH use and the associated outcomes in subgroups of post-resuscitation patients is needed.

Incidence of respiratory sensitisation and allergy to enzymes among employees in an enzyme producing plant and the relation to exposure and host factors

OBJECTIVES

Belonging to the group of high molecular weight respiratory sensitisers, microbial enzymes have been reported as a well known cause of occupational allergy, typically manifesting itself as rhinitis and/or asthma. High exposure to such high molecular weight sensitisers, and possibly also peak exposures, implies a higher risk than low exposure, but the exact relation between exposure, sensitisation and clinical allergy remains to be clarified. The authors sought to estimate the risk of respiratory enzyme allergy in an enzyme producing plant and to assess the relation between exposure indices and allergy.

METHODS

Retrospective follow-up study based upon data gathered from health surveillance since 1970. 1207 employees from production and laboratories were included. The level of enzyme exposure in the relevant departments was estimated retrospectively into five exposure levels based on 10-fold increments/decrements of the threshold limit value and other exposure information. The risk was estimated in an exponential regression survival model fitted with constant intensity for subperiods of time using maximum likelihood estimation.

RESULTS

During the first three years of a person's employment, the enzyme sensitisation and allergy incidence rates were 0.13 and 0.03 per person-year at risk, respectively. In the fitted models, exposure class did not correlate with the outcome variables. The risk of sensitisation decreased along the three decades, whereas the risk of allergy remained unchanged. The risk of sensitisation and allergy was doubled among smokers. Pre-employment atopy was only associated with sensitisation risk.

CONCLUSION

Sensitisation to enzymes decreased during the study period, possibly reflecting improvements in the working environment. A similar decrease could not be demonstrated for allergy to enzymes. Neither of the two outcomes correlated with exposure estimates, possibly because of the low precision of the estimates.

The effect of altering haemodynamics on the plasma concentrations of natriuretic peptides in heart failure

BACKGROUND

Natriuretic peptide levels reflect haemodynamics in patients with heart failure and may serve as biochemical markers of cardiac filling pressures. The purpose of this study was to detect differences in the kinetic profile between atrial natriuretic peptide (ANP), B-type natriuretic peptide (BNP) and their N-terminal fragments N-ANP and N-BNP, in response to rapid and persistent vasodilatation.

METHODS

Sixteen men and four women aged 63.0+/-10.4 (mean+/-S.D.) with symptomatic congestive heart failure (NYHA III) and pulmonary capillary wedge pressure (PCWP)>18 mm Hg, received a 24-h infusion of nitroglycerin (N=8) or nicorandil (N=12). A reduction of PCWP was achieved for the duration of the study. Natriuretic peptides were measured by radioimmunoassay at baseline, 1, 3, 6, 12 and 24 h.

RESULTS

PCWP and right atrial pressure fell rapidly and then increased modestly. ANP and N-ANP demonstrated a similar pattern. In contrast, BNP and N-BNP levels fell steadily throughout the observation period. This was accompanied by a continuous reduction of systemic vascular resistance (SVR). PCWP was highly correlated to the levels of all the natriuretic peptides. Using a longitudinal regression model evaluating responses over time, we found separate, significant relationships between all peptides and haemodynamic variables

CONCLUSION

The atrial natriuretic peptides reflect rapid changes in filling pressures while the B-type peptides respond much slower. B-type peptides are less sensitive to short-term changes in filling pressures, but should reflect changes in SVR better during vasodilator therapy.

Exercise training in congestive heart failure. A review of the current status

Traditionally exercise training was considered contraindicated in heart failure patients. However, during the last 15 years numerous small studies have demonstrated that training is safe in stable heart failure patients and that this intervention improves quality of life in this population. The beneficial effects include improved autonomic balance, reduced neurohumoral activation and reduced inflammatory response in addition to the direct effect on exercise capacity. Pooling of the available data from small randomized studies confirms the positive effect of training on morbidity, and also suggests that this type of intervention improves survival. Large scale studies are on-going to confirm the beneficial effects of training on mortality. This paper reviews the effects of exercise training in patients with the syndrome of heart failure and discusses the different types of training protocols and the tools for assessing the training effect in this population.

Occupational exposure to airborne proteolytic enzymes and lifestyle risk factors for dental erosion--a cross-sectional study

This study examined the hypothesis that occupational exposure to airborne proteolytic enzymes is associated with dental erosions on the facial surfaces of exposed teeth. Individuals (n = 425) working at a pharmaceutical and biotechnological enterprise (Novozymes A/S) were examined; their mean age was 35 years (range = 18-67 years) and 143 (34%) were women. Two hundred and two of these individuals were newly employed by the company. Occupational exposure was assessed from questionnaire and workplace information. For practical analytical purposes, individuals were categorized as either previously exposed to proteolytic enzymes or not. Information on relevant lifestyle factors and medical history was obtained from a questionnaire. The main effect measure was facial erosion, but lingual erosion indices and the presence of Class V restorations were also considered. The validity of these measures was shown to be very high. Adjusted for potential confounders, there was no association between history of occupational exposure to proteolytic enzymes and prevalent facial or lingual erosion. With respect to prevalence of Class V restorations, the association was significant. The present study did not support directly our primary hypothesis that occupational exposure to airborne proteolytic enzymes is associated with dental erosions on the facial surfaces of exposed teeth. However, the results indicate that exposure to proteolytic enzymes may lead to pronounced tooth substance loss, demanding treatment.

Assessing the effect of exercise training in men with heart failure; comparison of maximal, submaximal and endurance exercise protocols

AIMS

No consensus exists regarding the most appropriate exercise testing protocol for patients with congestive heart failure. This study describes the effect of exercise training on performance using three different protocols (maximal, submaximal and endurance testing) in patients with heart failure.

METHODS AND RESULTS

Thirty men (mean age 67+/-8 years) with congestive heart failure in NYHA class III (mean ejection fraction 32+/-5%) were evaluated prior to and following exercise training. A maximal exercise cycle test with gas exchange measurements, a submaximal 6 min walk test and an endurance treadmill test with blood lactate sampling were used to evaluate exercise capacity after 12 weeks of exercise training. There was a 44.6% (P<0.001) increase in work performed during the maximal cycle test, with no significant increase in peak VO(2). The distance covered by the submaximal 6 min walk test increased by 8.1% (P<0.001). Lactate measured as area under the curve during the matched work intensity treadmill endurance test was reduced by 19.5% (P<0.005).

CONCLUSION

We demonstrated a significant improvement in maximal, submaximal and endurance exercise capacity following 12 weeks of exercise training in patients with congestive heart failure. Endurance tests may be more sensitive and appropriate when assessing the efficacy of intervention in this population. Specifically, demonstration of reduced lactate production at matched work intensities suggests more efficient work and decreased dependence on anaerobic metabolism following training. Although maximal cycle tests are commonly used in clinical work, submaximal and endurance testing might be preferable for evaluating new treatment regimens in this population as they are easy to perform, are reproducible, and reflect daily tasks better than the maximal cycle test in this population.

A clinical index for evaluating and monitoring dental erosion

This study describes a new fine-scaled system for classifying initial and advanced dental erosions. The system includes the use of study casts of the teeth in an epoxy resin with an accurate surface reproduction. The severity of erosion on each tooth surface is scored according to six grades of severity. In addition, the presence of a Class V restoration and dental erosion on the same surface increases the erosion score, as it is assumed that the need for restorative treatment can be caused by the erosion. A high inter-examiner agreement was found when the present scoring system was used by two examiners on the same sample. With this prerequisite it is proposed that an index value for facial, oral, incisal/occlusal and cervical surfaces is calculated as the mean value of scores for the respective surfaces. The index values represent the severity of tooth substance loss in various locations of the oral cavity and are furthermore suitable for data analysis. The system is thereby well-suited for determining etiologic factors and monitoring the progression of erosion over time.

Comparison of the degree of hemodynamic tolerance during intravenous infusion of nitroglycerin versus nicorandil in patients with congestive heart failure

BACKGROUND

Continuous exposure to organic nitrates is associated with substantial tachyphylaxis. This study compares the development of tolerance during continuous intravenous treatment with nitroglycerin versus nicorandil over a 24-hour period.

METHODS AND RESULTS

Twenty patients with congestive heart failure and pulmonary capillary wedge pressure (PCWP) > or = 18 mm Hg were randomly assigned to nitroglycerin or nicorandil in a double-blind, crossover study. Doses were titrated to obtain a reduction of PCWP of at least 30% and then maintained. The mean pretreatment PCWP for nitroglycerin was 25.4 +/- 6.7 mm Hg, decreasing to 19.0 +/- 6.8 mm Hg at 24 hours. The values for nicorandil were 24.3 +/- 6.3 mm Hg and 15.6 +/- 4.5 mm Hg, respectively. Between-treatment difference was significant (p < 0.01). The difference between the minimal PCWP value and the 24-hour PCWP value for nitroglycerin was 5.1 mm Hg vs 1.4 mm Hg for nicorandil (p < 0.005). The mean systemic vascular resistance was 1418 +/- 355 dynes.sec.cm-5 before nitroglycerin infusion, decreasing to 1312 +/- 353 dynes.sec.cm-5 at 24 hours. Corresponding values for nicorandil were 1420 +/- 366 dynes.sec.cm-5 and 967 +/- 274 dynes.sec.cm-5. Between-treatment difference was significant (p = 0.005). Tachyphylaxis developed in 12 (60%) patients during nitroglycerin infusion versus three patients (15%) during nicorandil infusion.

CONCLUSION

This study demonstrates that intravenous nicorandil administration results in significantly less hemodynamic tolerance over a 24-hour period compared with nitroglycerin. This finding may represent a clinical advantage for nicorandil in the short-term treatment of patients with congestive heart failure.

Systemic thrombin generation and activity resistant to low molecular weight heparin administered prior to streptokinase in patients with acute myocardial infarction

One hundred patients were included in a randomized open trial to assess the systemic factor Xa (FXa) and thrombin inhibitory effect as well as the safety profile of low molecular weight heparin (LMWH) given subcutaneously in conjunction with streptokinase (SK) in patients with acute myocardial infarction (MI). The treatment was initiated prior to SK, followed by repeated injections every 12 h for 7 days, using a dose of 150 anti-Xa units per kg body weight. The control group received unfractionated heparin (UFH) 12,500 i.u. subcutaneously every 12 h for 7 days, initiated 4 h after start of SK infusion. All patients received acetylsalicylic acid (ASA) initiated prior to SK. Serial blood samples were collected prior to and during the first 24 h after initiation of SK infusion for determination of prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin III (TAT) complexes, fibrinopeptide A (FPA) and cardiac enzymes. Bleeding complications and adverse events were carefully accounted for. Infarct characteristics, as judged by creatine kinase MB isoenzyme (CK-MB) and cardiac troponin T (cTnT), were similar in both groups of patients. A comparable transient increase in F1 + 2, TAT and FPA was noted irrespective of heparin regimen. Increased anti-Xa activity in patients given LMWH prior to thrombolytic treatment had no impact on indices of systemic thrombin activation. The incidence of major bleedings was significantly higher in patients receiving LMWH as compared to patients receiving UFH. However, the occurrence of bleedings was modified after reduction of the initial LMWH dose to 100 anti-Xa units per kg body weight. In conclusion, systemic FXa- and thrombin activity following SK-infusion in patients with acute MI was uninfluenced by conjunctive LMWH treatment.

[Physical exercise and heart failure. A review article]

This review discusses the therapeutic value of physical exercise in patients with congestive heart failure. The possible circulatory, peripheral and metabolic mechanisms involved are discussed. Relevant clinical research in this field is reviewed. Physical training appears to be a safe and efficacious intervention in this large population.

[Pro-atrial natriuretic factor is predictive for the clinical status of patients with heart failure]

This study was undertaken in order to evaluate the relationship between N-terminal proatrial natriuretic factor [1-98] and routinely available measures of clinical status. Odds ratio estimates demonstrated a much higher risk of presence of left ventricular dysfunction and dilatation, pulmonary hypertension, and New York Heart Association function class III or IV with increasing proANF values. Analysis is simple and can be of practical value as a supplement in the assessment of cardiac status in this heterogeneous population.

Plasma proatrial natriuretic factor is predictive of clinical status in patients with congestive heart failure

Atrial stretch results in myocyte release of the prohormone atrial natriuretic factor (1-126). The N-terminal (1-98) fragment, proatrial natriuretic factor (proANF) is released on an equimolar basis with the C-terminal (99-126) active hormone and may be assayed simply due to in vitro stability. This study was undertaken to evaluate the relation between proANF and routinely available measures of clinical status. ProANF was sampled from 202 patients (median age 68 years [range 15 to 85], 77% men) recruited from an active outpatient heart failure clinic. Patients were subgrouped according to New York Heart Association functional class, radionuclide ejection fraction (EF), echocardiographic left ventricular (LV) end-diastolic diameter, and Doppler-determined systolic pulmonary arterial pressure. The median proANF (pmol/L) values for patients in New York Heart Association classes I, II, III, IV were 725, 1,527, 1,750, and 5,172, respectively. The proANF value for the group with EF > 40% was 1,534 versus 1,993 for EF < or = 40% (p < 0.05). The value for the group with LV diameter < 60 mm ws 838 versus 1,751 for LV diameter > or = 60 mm (p < 0.01). The value for the group with systolic pulmonary artery pressure < 45 mm Hg was 1,241 versus 2,660 for systolic pulmonary artery pressure > or = 45 mm Hg (p < 0.01). ProANF correlated better than the other variables with New York Heart Association functional class and was more closely associated with noninvasive measurements than New York Heart Association functional class.(ABSTRACT TRUNCATED AT 250 WORDS)

Cancer morbidity among employees in a Danish pharmaceutical plant

BACKGROUND

Workers in the pharmaceutical industry may be exposed to many potential carcinogens. We investigated cancer morbidity in a Danish plant where enzymes, insulin, antibiotics and sex hormones were produced in substantial quantities.

METHODS

Altogether 10,889 people ever employed (1964-1988) at the pharmaceutical plant were retrieved from the files of a compulsory pension fund, and followed-up in the nationwide Danish Cancer Registry (1964-1989). Site-specific standardized incidence ratios (SIR) were estimated, based on cancer rates for the national population. Information on risk factors for breast cancer, e.g. number of children, age at menarche and first delivery, obesity, and non-occupational use of sex hormones was obtained from samples of the female employees, and compared to equivalent variables from the general population.

RESULTS

The overall SIR for women was significantly elevated (n = 5554; SIR = 1.2). Excess risk was particularly seen for breast cancer (n = 97; SIR = 1.5), especially in a subgroup who had started work at the factory aged 30-39 and had continued to work for 1-9 years (SIR = 2.8). The SIR was near unity for men (n = 5335); however, three men with breast cancer versus 0.4 expected were found. Lifestyle components explained only about one-quarter of the excess female breast cancers. Proxy measures of intensity of occupational exposure to sex hormones or insulin showed no association with the risk for breast cancer.

CONCLUSIONS

It seems unlikely that either a single occupational factor or an unusual reproductive pattern can explain the elevated breast cancer risk. Therefore, the finding requires further study.

[Hazardous health effects of microwaves and radio waves]

About 4000 Danish employees may be significantly exposed to radiofrequency electromagnetic radiation (RF) or microwaves (MW) during work in the health sector or industrially. Exposure measurements and classifications are difficult, therefore, epidemiological as well as experimental research in the field is complicated. High exposure induces elevation of body temperature or local heating ("hot spots"). Some biological effects from RF/MW exposure seem to be mediated by heating, others are considered to be athermic. Epidemiological studies do not indicate that RF/MW should be carcinogenic, and experimental studies have not shown the radiation to be mutagenic or carcinogenic. Epidemiological studies among physiotherapists have indicated that RF may have reproductive effects. In one study, an association between ischaemic heart disease and exposure to RF is observed. The cataractogenic property of MW is supposed to be mediated by elevation in lens temperature following relatively high exposure. However, in the light of the problems in exposure classification, the epidemiological research may not be conclusive, and attempts should be made to improve the methods. In addition, Danish experience points out a number of methods of exposure reduction in the working environment.

Management of occupational risk to reproduction in a Danish county

In Denmark pregnant women are entitled to receive maintenance allowances if the working conditions are suspected to be harmful to the fetus. The aim of the study was to evaluate these preventive measures taken to reduce occupational hazards to reproduction in Denmark. In 1985 1,247 pregnancies were identified in Ribe county during a 6-month period. Three hundred and forty-five women employed at the beginning of the pregnancy in manufacturing industries, construction work, health services, or agriculture were interviewed by telephone concerning their working conditions and the measures taken to reduce possible occupational risks. The response rate was 85%. On the basis of the interviews the risks and the preventive measures were assessed. Out of 200 women who had no changes in the working conditions during pregnancy, 46 (23%) had a working situation which was considered potentially harmful. For 57 the working situation was changed during the first months of pregnancy because of an assumed risk. The remaining 37 were out of work or received maintenance allowances because of occupational hazards. In this study a greater awareness than expected about possible occupational risks was found, but in some instances occupational risks were overlooked or neglected.

[Digitalis therapy in patients with heart failure and sinus rhythm]

The role of digitalis therapy in patients with sinus rhythm and mild to moderate heart failure has been a subject of controversy. This review critically examines the relevant literature and specifically evaluates trials in this patient population. The pharmacokinetics and the pharmacodynamics of the most commonly prescribed agents are briefly discussed. The available evidence supports the use of this agent in patients with sinus rhythm and clinical signs of systolic dysfunction. Digitalis is not recommended as a routine when the primary cause of heart failure is diastolic dysfunction. The use of digitalis therapy in combination with diuretics and vasodilator therapy deserves further attention.

Gender-specific reproductive outcome and exposure to high-frequency electromagnetic radiation among physiotherapists

The aim of this case-referent study was to investigate reproductive hazards other than congenital malformations after exposure to high-frequency electromagnetic radiation. Cases and referents were sampled from a cohort of pregnancies of members of the Union of Danish Physiotherapists through linkage of the union file with national medical registers. Case groups were spontaneous abortions and children with low birth-weight prematurity, and stillbirth/death within one year. Exposure to high-frequency electromagnetic radiation before and during pregnancy was assessed through telephone interviews. As referents to the 270 cases, 316 pregnancies were randomly sampled. A total of 8.4% did not participate. Only 23.5% of the children born by the highly exposed mothers were boys. This value is a statistically significantly altered gender ratio showing a dose-response pattern. High-frequency electromagnetic radiation was furthermore associated with low birthweight, but only for male newborns. The other outcomes were not statistically significantly associated with exposure to high-frequency electromagnetic radiation.

Congenital malformations and exposure to high-frequency electromagnetic radiation among Danish physiotherapists

A cluster initiated the present case-referent study to assess the relation between exposure to high-frequency electromagnetic radiation and congenital malformations. Through the linkage of a cohort formed from a union file of Danish physiotherapists with complete national registers of pregnancy outcome, cases (pregnancies terminated by the birth of a malformed child) and referents were identified. From responses in a blinded telephone interview without knowledge of case status, exposure to high-frequency electromagnetic radiation in the first month of pregnancy was assessed. Indices reflecting duration of exposure ("time") and maximum level of exposure ("peak") were composed. After a 7% dropout 54 cases and 247 referents were interviewed. No statistically significant associations between pregnancy outcome and high-frequency electromagnetic radiation were found (odds ratio 1.7, 95% confidence interval 0.6-4.3).

Can exposure to electromagnetic radiation in diathermy operators be estimated from interview data? A pilot study

As preparation for a case-control study dealing with possible teratogenic property of short waves, a pilot study was conducted in order to compare exposure assessment from different sources. In 11 physiotherapy clinics, exposure assessments based on interviews within 1 week among the exposed physiotherapists were compared with exposure assessments based on observations including measurements. It was possible to discriminate between recent high and low peak exposure. Furthermore, an interview index reflecting the duration of the exposure correlated to some extent with the corresponding measurements.

Contact allergy to the fungicide benomyl?

Benomyl is a widely used fungicide. Contact allergy to benomyl has been reported in a few cases. We describe a group of 62 workers, exposed to benomyl. None had contact dermatitis from benomyl. It appears that benomyl at most is a weak sensitizer. We suggest that earlier-reported allergy may represent cross-reactions and/or that the development of contact allergy to benomyl requires previous exposure to other chemically related pesticides.

[Assessment of exposure to organic solvents. Reading the label or the legally compulsory instructions for use are not enough]

A case history is quoted to illustrate the description of exposure to organic solvents and to illustrate the following points: 1) It is not possible to assess the degree of exposure qualitatively by registering of legally correctly written labels and instructions for use. 2) Quantitatively correct prescriptions of the products do not reflect the quantitative conditions of exposure and 3) Thermodynamic calculations which also consider how the individual components influence the rates of vaporization of one another can describe the conditions of exposure more precisely.

Pain relief after major abdominal surgery: a double-blind controlled comparison of sublingual buprenorphine, intramuscular buprenorphine, and intramuscular meperidine

In a double-blind randomized study of three groups of 18 patients scheduled for major abdominal surgery the efficacy and side effects of sublingual buprenorphine were tested and compared to intramuscular meperidine and buprenorphine. Single doses of either 75 mg of meperidine, 0.4 mg of sublingual buprenorphine, or 0.3 mg of intramuscular buprenorphine were used. Patients given buprenorphine as sublingual tablets were significantly more conscious in the immediate postoperative period (Glasgow Coma Scale) than when given buprenorphine or meperidine intramuscularly. Median pain intensity differences (PID) showed equal pain relief, whereas the summarized pain intensity differences (SPID) were significantly higher in the intramuscular buprenorphine group compared to the meperidine group. Three cases of respiratory acidosis in the meperidine group required IPPV treatment, and one case in the intramuscular buprenorphine group required treatment. Sedation and nausea were the most common side effects in all three groups. We conclude that sublingual buprenorphine is useful for relief of postoperative pain and exhibited administrative advantages, when the patients were able to cooperate.