The genomic diversity of the Eliurus genus in northern Madagascar with a putative new species

Madagascar exhibits extraordinarily high level of species richness and endemism, while being severely threatened by habitat loss and fragmentation (HL&F). In front of these threats to biodiversity, conservation effort can be directed, for instance, in the documentation of species that are still unknown to science, or in investigating how species respond to HL&F. The tufted-tail rats genus (Eliurus spp.) is the most speciose genus of endemic rodents in Madagascar, with 13 described species, which occupy two major habitat types: dry or humid forests. The large species diversity and association to specific habitat types make the Eliurus genus a suitable model for investigating species adaptation to new environments, as well as response to HL&F (dry vs humid). In the present study, we investigated Eliurus spp. genomic diversity across northern Madagascar, a region covered by both dry and humid fragmented forests. From the mitochondrial DNA (mtDNA) and nuclear genomic (RAD-seq) data of 124 Eliurus individuals sampled in poorly studied forests of northern Madagascar, we identified an undescribed Eliurus taxon (Eliurus sp. nova). We tested the hypothesis of a new Eliurus species using several approaches: i) DNA barcoding; ii) phylogenetic inferences; iii) species delimitation tests based on the Multi-Species Coalescent (MSC) model, iv) genealogical divergence index (gdi); v) an ad-hoc test of isolation-by-distance within versus between sister-taxa, vi) comparisons of %GC content patterns and vii) morphological analyses. All analyses support the recognition of the undescribed lineage as a putative distinct species. In addition, we show that Eliurus myoxinus, a species known from the dry forests of western Madagascar, is, surprisingly, found mostly in humid forests in northern Madagascar. In conclusion, we discuss the implications of such findings in the context of Eliurus species evolution and diversification, and use the distribution of northern Eliurus species as a proxy for reconstructing past changes in forest cover and vegetation type in northern Madagascar.

Morphological variability or inter-observer bias? A methodological toolkit to improve data quality of multi-researcher datasets for the analysis of morphological variation

OBJECTIVES

The investigation of morphological variation in animals is widely used in taxonomy, ecology, and evolution. Using large datasets for meta-analyses has dramatically increased, raising concerns about dataset compatibilities and biases introduced by contributions of multiple researchers.

MATERIALS AND METHODS

We compiled morphological data on 13 variables for 3073 individual mouse lemurs (Cheirogaleidae, Microcebus spp.) from 25 taxa and 153 different sampling locations, measured by 48 different researchers. We introduced and applied a filtering pipeline and quantified improvements in data quality (Shapiro-Francia statistic, skewness, and excess kurtosis). The filtered dataset was then used to test for genus-wide sexual size dimorphism and the applicability of Rensch's, Allen's, and Bergmann's rules.

RESULTS

Our pipeline reduced inter-observer bias (i.e., increased normality of data distributions). Inter-observer reliability of measurements was notably variable, highlighting the need to reduce data collection biases. Although subtle, we found a consistent pattern of sexual size dimorphism across Microcebus, with females being the larger (but not heavier) sex. Sexual size dimorphism was isometric, providing no support for Rensch's rule. Variations in tail length but not in ear size were consistent with the predictions of Allen's rule. Body mass and length followed a pattern contrary to predictions of Bergmann's rule.

DISCUSSION

We highlighted the usefulness of large multi-researcher datasets for testing ecological hypotheses after correcting for inter-observer biases. Using genus-wide tests, we outlined generalizable patterns of morphological variability across all mouse lemurs. This new methodological toolkit aims to facilitate future large-scale morphological comparisons for a wide range of taxa and applications.

Traditional knowledge about medicinal plant in the remote areas of Wari Tehsil, Dir Upper, Pakistan

Traditional medicine is cheaper and easily available to local people, to care for most frequent diseases in the Northern parts of Pakistan. Our study aimed at inventorying medicine from local plants, documenting their uses, and assessing their market value in 2015-2018 during spring, summer, and winter seasons. A total of 15 trips were made, 5 in each season. Semi-structured interviews with 165 inhabitant's age range between 20-80 years were conducted, analyzed the data is analyzed using Relative frequency of citation(RFC), Use Value(UV), Fidelity Level(FL), Informants consensus factor(ICF), and Jaccard index(JI) to find the most frequent and well-known used species in the area. A total of 86 species belonging to 39 vascular plant families, 33 genera were documented as medicinally important. Family Asteraceae was observed as the dominant family among all the families with 10 species, the leaf was the most used parts and decoction 36% was the most preferred preparation type. Herb was the predominant life form (67%). The maximum UV (0.92) was demonstrated by J. adhatoda L. species, while A. sativum L. shows maximum RFC (0.58), the highest ICF value represented by diarrhea and dermatitis 0.92, and high FL value is recorded 100%. According to our collections, wild species were 45%, invasive species were 38% and cultivated 17% recorded, dicots species were recorded more 81%. Seven 7 medicinal species is being economically important and export to the local and international market of the world, whereas P. integrima L. species were the most exported species according to the local dealers. The investigated area is rural and the local people depend on the area's plants for their health needs, and other uses like a vegetable, fuelwood, fodder, etc. The current result of RFC, UV, ICF, FL, and JI shows that medicinal flora needs to be pharmacologically and phytochemically investigated to prove their efficacy. The documentation of medicinal knowledge is important to preserve this precious old knowledge before it is lost forever, due to technological and environmental changes in the world.

Distribution and conservation status of the endangered Montagne d’Ambre fork-marked lemur (Phaner electromontis)

The geographic distribution of a species can provide insights into its population size, ecology, evolution, and how it responded to past (and may respond to future) environmental change. Improving our knowledge of the distribution of threatened species thus is a high priority in assessing their conservation status. However, there are few data available for many recently described yet understudied and potentially threatened primate taxa, making their conservation difficult. Here, we investigated the distribution of the Montagne d’Ambre fork-marked lemur, Phaner electromontis, a threatened nocturnal primate endemic to northern Madagascar and classified as Endangered by the IUCN. Because fork-marked lemurs are highly vocal, we used acoustic surveys to assess the species’ presence-absence and relative population density within 66 distinct forest survey sites in northern Madagascar. Further, we compared data among five forest types within the study area and investigated the relationship between relative population density and climate variables. We report the presence of P. electromontis in 22 study sites; several of these populations were unknown previously. Although we found P. electromontis most frequently in dry-transitional forests, our results suggest that geography (spatial autocorrelation) rather than environmental variables explains the species’ distribution. We hypothesize that environmental unpredictability and gummivory, combined with the presence of several distinct Phaner species in the studied area, could explain the observed distribution.

Genetic and morphological diversity of mouse lemurs (Microcebus spp.) in northern Madagascar: The discovery of a putative new species?

Tropical forests harbor extremely high levels of biological diversity and are quickly disappearing. Despite the increasingly recognized high rate of habitat loss, it is expected that new species will be discovered as more effort is put to document tropical biodiversity. Exploring under-studied regions is particularly urgent if we consider the rapid changes in habitat due to anthropogenic activities. Madagascar is known for its extraordinary biological diversity and endemicity. It is also threatened by habitat loss and fragmentation. It holds more than 100 endemic primate species (lemurs). Among these, Microcebus (mouse lemurs) is one of the more diverse genera. We sampled mouse lemurs from several sites across northern Madagascar, including forests never sampled before. We obtained morphological data from 99 Microcebus individuals; we extracted DNA from tissue samples of 42 individuals and amplified two mitochondrial loci (cytb and cox2) commonly used for species identification. Our findings update the distribution of three species (Microcebus tavaratra, Microcebus arnholdi, and Microcebus mamiratra), including a major increase in the distribution area of M. arnholdi. We also report the discovery of a new Microcebus lineage genetically related to M. arnholdi. Several complementary approaches suggest that the newly identified Microcebus lineage might correspond to a new putative species, to be confirmed or rejected with additional data. In addition, morphological analyses showed (a) clear phenotypic differences between M. tavaratra and M. arnholdi, but no clear differences between the new Microcebus lineage and the sister species M. arnholdi; and (b) a significant correlation between climatic variables and morphology, suggesting a possible relationship between species identity, morphology, and environment. By integrating morphological, climatic, genetic, and spatial data of two northern Microcebus species, we show that the spatial distribution of forest-dwelling species may be used as a proxy to reconstruct the past spatial changes in forest cover and vegetation type.

Flame figures in linear IgA bullous dermatosis: a novel histopathologic finding

BACKGROUND

Linear IgA bullous dermatosis (LABD) is an autoimmune subepidermal blistering disease usually with a neutrophil rich inflammatory infiltrate, and characterized by linear IgA deposition at the basement membrane zone (BMZ), and neutrophil predominant dermal inflammation. We report a case of LABD with numerous eosinophils and flame figure formation, a unique histopathologic finding not previously reported. A 69-year-old woman presented with a rapidly progressive, intensely pruritic rash over forearms, breasts, axillae, hips, and thighs. Thelesions were comprised of annular vesicles and bullae with hemorrhagic crusts and erosions. The clinical differential diagnosis included bullous pemphigoid(BP), LABD, and epidermolysis bullosa aquisita (EBA).

RESULTS

A biopsy from a bullous plaque on the wrist revealed a subepidermal blister with neutrophils and numerous eosinophils with flame figure formation.Direct immunofluorescent (DIF) microscopy revealed linear deposition of IgA at the BMZ.

CONCLUSIONS

Although unusual, the combined findings supported a diagnosis of LABD. Increased eosinophils may be associated with drug-induced LABD and may explain the numerous eosinophils in our case. It is important to be aware of this finding as the pathology may easily be misdiagnosed as BP, or possibly bullousWells syndrome. This case emphasizes that combined clinical, pathologic, and DIF findings are essential in the diagnosis of bullous dermatoses.

Removal of silver and antimony radionuclides from low-level liquid radioactive waste of a research reactor through different scavenging precipitations

After upgrading the Pakistan Research Reactor-1, the amount of liquid waste and its increased radioactivity content necessitated a pre-disposal treatment to bring the activity down to disposal limits. Amongst several radionuclides in the waste, 110mAg and to some extent 124Sb were of our concern due to their higher production rate. Different possible treatment processes were considered for the treatment of low-salt, low-level liquid waste of the institute. Making use of insolubilities and scavenging properties of certain precipitates of metal ions, some experiments on the actual waste samples were performed for the decontamination of the piled up waste effluent. Suitable reagent(s) and the optimum doses were to be investigated for the treatment and conditioning of the wastewater. Different scavenging agents like ferric chloride, ferrous sulfate, stannous chloride, in situ precipitated manganese hydroxide and lanthanum nitrate were studied for the removal of these two radionuclides. Selectivity of Fe2+ and Fe3+ as scavengers for silver and antimony was investigated. Excellent Decontamination Factors (>1000) were obtained very cost effectively with some of the reagents tried. Based on these experiments, a working procedure making use of Fe(II) hydrous oxide scavenging precipitation for the chemical treatment of the waste effluent was optimized. These experiments are presented.

A practical profile of integrated safety assessment of near-surface disposal of radwaste at PINSTECH

Near-surface or shallow land disposal of radioactive waste has been the primary practice at the Pakistan Institute of Nuclear Science and Technology (PINSTECH). The adopted choice of this mode of disposal has been based on a study of the site and the quality and quantity of waste generated at the 5 MW reactor with HEU fuel. Specific measures regarding the radiation safety of the workers and environmental protection have been adopted. The waste disposal operations are conducted to meet local regulatory requirements, IAEA recommendations and internationally endorsed principles such as ALARA (as low as reasonably achievable - economic, social and other relevant factors being considered). The data obtained through the years of operational and management experience have manifested the robustness of the disposal system and reliability of the disposal criterion, and have also served to further refine the latter. Consequently, confidence in the current shallow-land-burial practices has increased. Radiological safety of these practices has been assessed by addressing different aspects of the safety and disposal system. These parameters, as indices of a non-exclusive and operational safety model, are presented.

Radiation protection aspects of shallow land disposal of low and intermediate level liquid and solid radioactive waste at PINSTECH

Operation of Pakistan Research Reactors 1 and 2, radioisotope production plants, and allied laboratories at the Pakistan Institute of Nuclear Science & Technology (PINSTECH) generates radioactive waste effluents of low and intermediate level. These waste materials are managed in a way to keep the human health and the environment free of radiation associated hazards. The prime practice has been of shallow ground or near-surface disposal type. Different measures and operational procedures at the institute, in step with the international norms for the management of low and intermediate level waste, have been adopted. To ensure the safe disposal practices and radiation safety of the workers and of the general public, radiological safety related routines are practiced with due concern. Some safety aspects of the prevailing practices are discussed in this presentation.

[Future molecules in heart failure]

TODAY: The management of heart failure (HF) has considerably progressed over the last two decades. Treatment today relies on prevention and treatment of congestion (limited salt intake, diuretics, converting enzyme inhibitors) and limiting neurohormone stimulation (converting enzyme inhibitors +/- aldactone, beta-blockers). IN THE YEARS TO COME: Based on new concepts, several therapeutic strategies are interesting: blocking over vasoconstrictor systems which have not been taking into account; stimulation of vasodilator and natriuretic systems; modulation of cardiac remodelling; modulation of the immune and inflammatory systems; modification in intrinsic contractility; prevention of rhythm disorders. Among these differing strategies and molecules, it is not easy to predict those that will change the HF prognosis. In any event, their efficacy and safety remain to be demonstrated with large cohort randomised studies. THE PRINCIPLES: To reduce the number of drugs administered, two options appear particularly interesting: measurement of hormone levels (BNP) in order to adjust treatment and administration of molecules with greatest efficacy and safety profiles; limit cardiac remodelling by using new imaging techniques to detect it more precisely and select the molecule(s) exerting the required effect. To target the new molecules better, patients should be classified according to their etiology, stage and progressive profile of their disease, cardiac remodelling, expression of principle endocrine systems and pro-inflammatory cytokines, expression of inflammatory and immune systems and inherent genetic characteristics and response to treatment. This would permit the adaptation of treatment to each individual patient with heart failure.

[Medical record, source of conflict]

Patients' right to information is strictly regulated by the French Code of Public Health that establishes the legal framework for delivering medical information. The Code of Medical Deontology also contains several articles concerning patients' rights, medical information, and medical secret. The patient's right to information must not be confounded with medical file property rights which is an ambiguous notion that has not yet acquired a perfectly acceptable legal definition satisfying all concerned. Currently, the physician, designated by the patient, is the only person legally authorized to deliver to that patient the desired information.

[Arterial hypertension due to compression of the renal artery, revealing ovarian cancer]

BACKGROUND

The etiologic work-up of hypertension with hyperaldosteronism and elevated serum renin includes search for renal artery stenosis. Intrinsic stenosis is a common finding, but hypertension secondary to extrinsic compression of the renal artery is exceptional.

CASE REPORT

A 48-year-old woman with an uneventful history was hospitalized for recent onset hypertension. Laboratory tests showed hypokaliemia, and elevated aldosterone and renin. Duplex Doppler exploration of the renal vessels evidenced extrinsic compression of the left renal artery by a tumoral mass found to be a nodal metastasis at surgery. Pathology reported cancer of the ovary. Blood pressure, and aldosterone and renin levels returned to normal after complete tumor resection. No antihypertensive treatment was required.

CONCLUSION

This is undoubtedly the first case of metastatic cancer of the ovary revealed by hypertension; it can be added to the list of 49 other published cases of extrinsic compression of the renal artery by various causes leading to hypertension. In most cases, surgical removal of the obstacle or nephrectomy provided cure of the hypertension.

[Do arrhythmias after infarction deter patients from smoking?]

Although the short-term outcome of patients treated by thrombolysis during the acute phase of myocardial infarction is now well known, data concerning the repercussions of the coronary accident on smoking are less clearly established. This aspect is particularly important, as cessation of smoking is one of the most effective measures in the context of secondary prevention, with an excellent cost-benefit ratio. Between 1985 and 1991, 218 consecutive patients underwent thrombolysis for myocardial infarction. With a follow-up of 35 +/- 20 months, 11.5% of patients have died, including 6% while in hospital. A questionnaire was sent to 193 surviving patients with a response rate of 97.4%, 27.3% of patients continued to smoke after the myocardial infarction. Smoking patients were younger (p = 0.001) and had generally returned to work (p = 0.05). Continuation of smoking was not influenced by either the patency of the artery or the type of revascularization, and was not correlated with residual symptoms. The frequency of arrhythmias during the acute phase was not related to previous smoking. On the other hand, smoking patients who survived after an infarction appear to quit smoking twice as frequently when they had experienced a cardiac arrhythmia during the acute phase of the infarction (p = 0.005), as confirmed by multivariate analysis. Can the "stress" induced by the arrhythmia, possibly combined with the doctor's reactive anxiety explain cessation of smoking in these patients? If so, it would open new horizons in terms of secondary prevention of myocardial infarction.

[Exercise training and rehabilitation techniques in patients with coronary disease]

Exercise rehabilitation is widely prescribed for patients with coronary artery disease and requires the same rigorous approach as physical training in athletes. Training techniques have been carefully described, but the precise physiological justification remains to be elucidated. In order to target the physiological mechanisms which rehabilitation training is designed to improve, it is necessary to have a coherent strategy and apply the techniques with a clear idea of the objective to be attained. We describe the programme we propose to our patients. First, patients are advised to fraction their exercise into short relatively intense periods of exertion separated by rest periods as long as the exertion period. This method is designed to develop the "power" of the aerobic energy system. Later, we progressively introduce longer periods of training at moderate intensity. This part of the rehabilitation is designed to develop the "capacity" of the aerobic system. The decision to develop work capacity is based on the patient's response to the first part of the rehabilitation programme.

[Practical value of the detection of silent myocardial ischemia in patients with coronary disease using Holters]

The prognosis of painless myocardial ischemia is similar to that of symptomatic ischemia. The Holter technique (and solid memory Holter in particular) is a simple method of detection which, taken together with exercise testing, enables the identification among coronary disease patients of a high risk group in whom effort ischemia is accompanied by episodes of ischemia under everyday conditions and in whom additional investigations (exercise thallium scan then coronary arteriography) and appropriate treatment, including transluminal angioplasty and aorto-coronary bypass if necessary, may be required. The role of drug treatment in silent ischemia has not yet been clearly defined. While electrical ischemia regresses significantly with the majority of standard drug regimens, and beta-blockers in particular, none has yet been confirmed as having a preventive effect against serious events following on from silent myocardial ischemia.

[Diffuse cholesterol embolism after fibrinolysis for myocardial infarction]

The authors report the case of a 57 year old man admitted to hospital 3 hours after the onset of an infero-latero-basal infarct who underwent thrombolytic therapy with intravenous streptokinase, in whom the immediate outcome was complicated by multiple cholesterol embolisation which cause renal failure, mesenteric ischemia, medullary ischemia and livedo reticulosis of the lower half of the body complicated by gangrene of the toes, despite the fact that cardiac catheterisation had not been performed. This case (fifth reported case) of multiple cholesterol embolisation from the abdominal aorta caused by thrombolysis is the earliest presentation of this complication in the literature.

[Efficacy of intravenous milrinone in the treatment of acute congestive cardiac failure. Results of a French multicenter study]

The hemodynamic effects and safety of milrinone, a phosphodiesterase inhibitor, were studied in 57 patients in the acute phase of cardiac failure. The drug was given intravenously as an initial push dose of 50 micrograms/kg in 10 min followed by a 24 hour infusion at the dose of 0.5 micrograms/kg/min. Maximal response was obtained after 15 min and persisted throughout the infusion. Cardiac index rose by 40%, while pulmonary capillary pressure fell from 25 mmHg to 17 mmHg (-30%) by the fifth minute of treatment. Mean pulmonary artery pressure fell by 20% by the 15th minute. Systemic resistance decreased by 26% and pulmonary vascular resistance by 22%. All these variations were significant. Heart rate and systemic blood pressure remained stable. Study of three sub-groups: digoxin vs non-digoxin, sinus rhythm vs atrial fibrillation, and coronary patients vs non-coronary patients, revealed no significant difference. Safety of the drug was good, no extra-cardiac actions having required interruption of the infusion. Stoppage was made necessary by two instances of ventricular tachycardia. Improved hemodynamic effects and the good safety/acceptability of the drug indicate that milrinone is a treatment of choice in cardiac failure.

[Hemodynamic study of intravenous milrinone in 26 patients with NYHA class III or IV cardiac failure]

The hemodynamic effects of milrinone (WIN 47203) were studied in 26 NYHA Class III or IV patients. The compound was administered intravenously using a protocol including an initial push dose of 50 micrograms/kg in 10 min, followed by a 24 hour infusion at the dose of 0.5 microgram/kg/min. Maximal response was obtained after 15 min and persisted during the infusion: cardiac index increased from 2.08 +/- 0.36 l/min/m2 to 3.09 +/- 0.68 l/min/m2, while capillary pressure fell from 25 mmHg to 16-17 mmHg. These variations were significant (p = 0.01). Heart rate was stable. Mean peripheral blood pressure fell modestly (6%). Systemic vascular resistance fell by 30% and pulmonary vascular resistance by 20%. All these results confirmed the beneficial effect of this inotropic agent administered intravenously. The increase in ventricular premature contractions noted by many justifies the careful surveillance of these patients by monitoring.

[Primary isolated dissection of the left anterior descending coronary artery]

The authors report the case of a 30 year old Senegalese man admitted with an acute antero-septo-apical myocardial infarction which was fibrinolysed at the 5th hour. Coronary angiography showed dissection of the left anterior descending artery. This young patient with no previous medical history or cardiovascular risk factors had an abnormal skin biopsy showing proliferation of the elastic tissues. Eight months after the infarct the patient is asymptomatic and the appearances of dissection have disappeared. This case is original because the dissection occurred in a man, affecting the left anterior descending artery, with a good outcome after fibrinolysis (4th case), the angiographic regression of the arterial lesion and the possible pathogenetic mechanism of disease of elastic tissues.

[Silent myocardial ischemia during hemodialysis in patients with chronic renal insufficiency]

A prospective search for episodes of silent myocardial ischaemia (SMI) was carried out during sessions of haemodialysis in 62 patients with chronic renal failure and was positive in 37.1% of the cases. The occurrence of SMI is correlated with the number of cardiovascular risk factors (p = 0.008) and particularly with diabetes (p = 0.012), smoking (p = 0.007) and age (p = 0.02), as well as with the type of nephropathy that had caused the renal failure (p = 0.02). During a 6-month follow-up two patients died; both had silent myocardial ischaemia on Holter recordings. In these anaemic patients, haemodialysis might sensitize the detection of ischaemia by the concomitant occurrence of hypotensive, hypovolaemic or hypoxic episodes, thus playing a aggravating role. The existence of such episodes characterizes a subgroup of patients at high cardiovascular risk for whom the prognosis and the best therapeutic approach remain to be determined.

[Frequency of painless myocardial ischemia during hemodialysis in 50 patients with chronic kidney failure]

The authors carried out a prospective study to determine the frequency of silent ischemia (SI) in 50 consecutive patients with end stage renal failure during dialysis by Holter monitoring. Twenty patients had SI (40%). This event was related to the number of cardiovascular risk factors (p = 0.0025), principally diabetes, smoking and the underlying renal disease (p = 0.018), and to a history of coronary artery disease (p = 0.0015). Two patients died during the nine months follow-up period and both had SI on Holter monitoring. Dialysis therapy in anaemic patients may predispose to and facilitate the detection of myocardial ischemia by the simultaneous interplay of hypotension, hypovolemia, hypoxia and tachycardia. The detection of these ischemic events may allow identification of a subgroup of dialysis patients with a high cardiovascular risk. The prognosis of these patients and best therapeutic approach require further study.

Prehospital use of APSAC: results of a placebo-controlled study

Thrombolytic treatment efficacy is greater when the delay between onset of pain and treatment is short. To give treatment before admission to a coronary care unit, responsibility needs to be transferred from cardiologists to other physicians working in mobile care units. We conducted a 2-part feasibility study to investigate this strategy. Part 1 evaluated the diagnostic accuracy of mobile care unit physicians. Results from this study indicate that with regard to the diagnosis of acute myocardial infarction, the risk of a wrong diagnosis is low. Part 2 was a placebo-controlled trial involving 100 patients in which 57 received anisoylated plasminogen streptokinase activator complex (APSAC) (30 U) at home and 43 received placebo at home. Patients receiving placebo at home were reevaluated on arrival in a coronary care unit and received APSAC (30 U) if indicated. The main results were that (1) diagnostic accuracy was good--all patients had an acute coronary syndrome and 97 of 100 patients had myocardial infarction; (2) time gain was approximately 60 minutes; (3) coronary patency rate was 72%; (4) ejection fraction was higher in the prehospital group (56.7%) than in the control group (53.4%), but the difference was not significant; (5) there was no rhythmic or bleeding complication related to the prehospital treatment; (6) 5 patients died from cardiogenic shock--2 between home and hospital and 3 in the hospital (3 received thrombolytic treatment at home and 2 received placebo at home and APSAC in the hospital); and (7) prehospital administration of APSAC did not induce a delay in arrival to the coronary care unit.(ABSTRACT TRUNCATED AT 250 WORDS)

[Socioeconomic implications of the practice of thrombolysis in the acute stage of myocardial infarction]

The use of variegated and costly thrombolytic agents for the treatment of myocardial infarction in its acute phase may have medico-social advantages. In the present study, these advantages were evaluated after one year from two age and sex matched populations: 40 patients who underwent thrombolysis and 38 patients who did not. Compared with the first hospitalizations, the difference was + 4,000 francs, rising to + 11.000 francs with the drug Eminase. A questionnaire including medical, social and economic data was sent to the 78 patients and was filled by 63 of them, remaining unanswered by one patient who had thrombolysis and 10 patients who did not. Readmission to hospital showed a 44.000 francs difference to the benefit of patients who underwent thrombolysis. Ancillary care and return to work were similar in both groups. Cost expectancy was 119.500 francs for patients who had thrombolysis and 122.000 francs for those who did not. Thrombolysis therefore is a cost reduction factor, but its influence on costs is less pronounced when it is performed soon after the onset of myocardial infarction. Thrombolysis is more expensive when carried out at home than in hospital. In this study, the excess cost (+ 5.000 francs) was due to the relatively small number of patients and to the loss of professional activity which may be an uncertain factor. Mortality at one year was nil when thrombolysis was performed within the first two hours (12 patients) and rose to 16.6 percent between 2 and 3 hours (18 patients) and 30 percent after 3 hours (10 patients). Conducted on a necessarily limited number of patients, this multiple criteria study was also aimed at establishing a method to evaluate the health expenditures imposed by the introduction of new and costly treatment in the management of myocardial infarction.

[Home thrombolysis for myocardial infarction. A multicenter study of the feasibility and evaluation of short-term prognosis]

It has been proven since 1986 that in myocardial infarction the sooner thrombolysis is performed the better. Forty-four patients were selected to enter a double-blind randomized trial in which they received either an acylated plasminogen streptokinase activator complex or a placebo. The injections were given intravenously at home within the first 3 hours (within the first 2 hours in 26 of them), by doctors from Mobile care units. This home treatment in the acute phase made it possible to gain 75 minutes on average, and up to 90 minutes when it was performed by an anaesthetist trained in emergency management. No serious complication, such as haemorrhagic or allergic reaction, occurred, and arrhythmia was no more frequent in the treated group than in the placebo group. Home thrombolysis did not delay admission to a cardiology Intensive Care unit (66 min. versus 64 min). Mean coronary patency was 75 per cent, and up to 82 per cent, in patients treated within 2 hours of the first symptoms. There was no significant difference between areas of reperfused or not reperfused patients in relation to time (P less than 0.08). Diagnosis sensitivity was 100 per cent. Thus, home thrombolysis is feasible and safe when performed by trained emergency medical teams and when criteria for inclusion and exclusion are fulfilled.

Prehospital administration of anisoylated plasminogen streptokinase activator complex in acute myocardial infarction

25 patients have been included in a randomised trial aimed to compare prehospital and hospital administration of anisoylated plasminogen streptokinase activator complex (AP-SAC). Patients were first seen, at home, by a noncardiologist doctor working in a mobile-care unit and were then evaluated for entry into the study. If they had evidence of myocardial infarction lasting for less than 3 hours and if there was no contraindication to thrombolytic therapy they were randomly allocated to APSAC 30U or placebo. They were next referred to an intensive coronary unit (ICU). On arrival in the ICU patients were reevaluated and received APSAC if they had previously received placebo. For 24 patients, diagnosis of myocardial infarction was confirmed. One patient died at home after having received placebo. There was 1 hospital death. At-home injection was made within a median of 124 minutes after the beginning of pain, whereas hospital administration was made after a median of 180 minutes. On a clinical basis reperfusion occurred in 16 out of 21 evaluable patients. Four patients had coronary artery bypass graft surgery and 9 had angioplasty. We conclude that prehospital administration of APSAC is feasible, well-tolerated and is a good way to shorten the delay of thrombolytic treatment in myocardial infarction.