Overview of recent clinical trials in heart failure: what is the current standard of care?

Heart failure develops as a consequence of cardiac injury. As the heart begins to fail to meet the body's metabolic demands, the renin angiotensin aldosterone system (RAAS) and the sympathetic nervous system are activated. These interrelated systems act in concert to facilitate cardiac output and tissue perfusion. Though these neurohormonal systems are initially compensatory, evidence suggests that they promote deleterious cardiac remodeling and myocyte destruction. Recent studies in patients with heart failure have targeted the RAAS and sympathetic nervous system for therapeutic intervention. This article reviews major recent multicenter, randomized, double-blind, and placebo-controlled trials in heart failure that have resulted in a new standard of care for patients with this devastating disease.

Hospitals do not inform GPs about medication that should be monitored

BACKGROUND

General practitioners are now asked to prescribe drugs that, due to possible risks and side effects, had previously been prescribed almost exclusively at hospital.

OBJECTIVE

To assess the quality of hospital letters as the key communication between hospitals and GPs.

METHOD

Hospital letters examined using a predetermined protocol.

RESULTS

Of 224 patients identified who were taking drugs that required regular monitoring, 173 were commenced in hospital. Fewer than one in five (30; 17%) hospital letters indicated that there was a risk associated with the drug or that it should be routinely monitored. Monitoring frequency was identified on only 14 occasions and the majority of letters (129; 74. 6%) did not state who was to be responsible for ongoing monitoring (either GP or hospital). Information was slow to arrive at the practice and, in 12% of cases, the hospital letter had not arrived within 14 days of commencement of medication.

CONCLUSION

The information provided in hospital letters is insufficient to allow GPs to put structures in place to monitor drug therapy.

[Handling of thyroid diseases: usefulness and limitations of rapid and fine-needle percutaneous biopsy]

Fine needle aspiration biopsy of the thyroid (FNAB) has become an accepted procedure for evaluation of the thyroid nodule, with 899 performed at the Lahey Clinic from 1981 to 1990. We examined them by medical record, pathology, and cytology review, with follow-up by chart or personal communication. Three-hundred-forty-five came to surgery, of which 188 (34%) were malignant; the specificity of the aspirate was 97%, sensitivity 92%, with false negative of 8% and false positive of 3%. By comparison, the frozen section had a false negative rate of 1% and false positive rate of 5%. In combination with frozen section, the fine needle aspirate result improved the accuracy of the intraoperative estimate of malignancy (p = 0.03). When the aspiration was benign but the lesion was clinically suspicious, a cancer was found at surgery in 13% of cases. Of the patients observed for a minimum of 5 years, 1.3% developed a carcinoma. Both cases had a non diagnostic FNAB None of the patients with a clinical and cytological benign lesion developed cancer. The complication rate of FNAB was 1.3% FNAB is a helpful and low risk diagnostic procedure but it needs to be done and read appropriately and its result used within the clinical context. Each medical team needs to monitor their results (continued quality control).

Prediction of capsular perforation and seminal vesicle invasion in prostate cancer

PURPOSE

Capsular perforation and seminal vesicle invasion are unfavorable prognostic factors in prostate cancer. Accurate preoperative prediction of these factors would be clinically useful for planning treatment, especially in patients being considered for radiation therapy, nerve sparing radical prostatectomy and watchful waiting. However, current methods are imprecise at predicting the presence and extent of these factors. We determined which combination of commonly available preoperative variables provides the best prediction of capsular perforation and seminal vesicle invasion of patients with clinically localized prostate cancer.

MATERIALS AND METHODS

We reviewed the preoperative medical records and biopsy findings from 314 patients with clinical stages T1cN0M0 to T2cN0M0 cancer who underwent radical retropubic prostatectomy and bilateral pelvic lymphadenectomy between September 1991 and June 1993. Radical prostatectomy specimens were embedded and evaluated by whole mount sections.

RESULTS

Capsular perforation was observed in 104 patients (33.1%) and seminal vesicle invasion was noted in 46(14.6%). Preoperative variables predictive of capsular perforation and seminal vesicle invasion on univariate analysis were serum prostate specific antigen (PSA) concentration, clinical, stage, Gleason primary and secondary patterns, Gleason score, nuclear grade, perineural invasion and percent cancer in the biopsy specimens. On multivariate analysis, independent prognostic factors for capsular perforation and seminal vesicle invasion were PSA, Gleason score and percent cancer in the biopsy specimens.

CONCLUSIONS

The combination of serum PSA concentration, Gleason score and percent cancer in the biopsy specimens provides the best prediction of capsular perforation and seminal vesicle invasion. Models based on this combination of factors may be clinically use to stratify patients for nonoperative treatment.

Stressful nurses: the effect on patient outcomes

The article describes a study that measured, over a 3-month period, staffing problems, including turnover rates; nurse incidents, including absenteeism, back injuries, and needle sticks; and patient incidents, including falls and medication errors. The self-reported stress of the nurses caring for these patients was recorded over the same 3-month period. Data showed that a relatively strong relationship exists between a hospital unit's Stress Continuum Scale (SCS) and the occurrence of patient incidents. The relationship between the SCS and personal incidents and nurse injuries appears weak, as does the relationship between staff turnover and stress. Lagging staff turnover by 1 month resulted in a moderate association with the SCS, however.

Nurses' Attitudes Toward Nursing Process as Measured by the Dayton Attitude Scale

This study measured the knowledge of and attitudes toward the nursing process held by nurses who provide direct patient care. The Dayton Attitude Scale Toward Care Planning (DASC) was returned by 1,096 nurses practicing in nine hospitals. Overall, participants were knowledgeable of the nursing process and held a relatively positive attitude toward the nursing process and nursing diagnosis. Higher nursing degrees were associated with more positive attitudes. The most common barrier to the use of the nursing process was insufficient time. The study found that less than 30% of the subjects liked the way care planning was done. These findings suggest that improving care planning systems would further promote consistency in the process.

Evaluation of diagnostic tests in the differential diagnosis of primary aldosteronism: unilateral adenoma versus bilateral micronodular hyperplasia

Effective management of primary aldosteronism is dependent upon correct localization of excessive aldosterone production. We report our results of localization studies in patients with biochemically and pathologically confirmed primary aldosteronism. Retrospective chart review identified 69 patients with unilateral adrenal adenoma and 11 with adrenal hyperplasia. Correct unilateral versus bilateral localization of excessive aldosterone production was predicted in 70% versus 71%, respectively, by adrenal venography, 100% versus 63% by adrenal vein hormone sampling, 46% versus 56% by adrenal nuclear scanning and 69% versus 13% by anomalous postural decline of aldosterone. Adrenal computerized tomography appeared to localize correctly 86% versus 80% of the lesions. Unilateral adrenalectomy normalized blood pressure in 79% of the patients with unilateral adenomas versus only 18% of those with adrenal hyperplasia. Once primary aldosteronism is confirmed, localization by adrenal vein sampling, adrenal venography and adrenal computerized tomography is most effective in directing antihypertensive therapy.

Patients in acute care settings. Which health-care services are provided?

Studies have shown that early discharge planning, multidisciplinary care, and a focus on functional abilities for older adults do reduce acute care hospital readmissions. Of the 101 records reviewed of acute care admissions 75 years of age and older, 36 had no multidisciplinary service documented and 75 had no discharge planning documented within 48 hours of admission. Eleven functional activities were assessed and documented in one record with a range of 4 to 11 activities assessed in the remaining 100 documents. Identifying and filling gaps in care provided to this age group might provide substantial cost savings, improve care, and decrease complications. Advocacy, coordination of care, and greater knowledge may be keys to narrowing these service gaps.

Identification of the protein responsible for hepatic system N amino acid transport activity

In the liver, glutamine utilization may be limited by the rate of transport across the plasma membrane by the System N carrier. System N-mediated transport activity has been solubilized from rat liver plasma membrane, partially purified, and then reconstituted into proteoliposomes. To identify the System N carrier protein, monoclonal antibodies were generated against the protein fraction enriched for System N activity. Two antibodies , 3E1-2 and 1E7-3, inhibited System N activity in hepatocytes. These antibodies also immunoprecipitated System N activity from a mixture of solubilized proteins and were specific for antigen recognition in that neither immunoprecipitated System A activity. The antibody recognized a single protein of molecular size 100 kDa by immunoblot analysis. Recognition of this protein by the antibody increased in parallel with the enrichment of System N activity in solubilized membrane fractions. These data suggest that a 100-kDa plasma membrane protein mediates System N transport activity in rat hepatocytes.

Quantitative DNA analysis in breast carcinomas: a comparison between image analysis and flow cytometry

We compared the results of quantitative DNA analysis of fresh tumor tissue from 50 invasive breast carcinomas by image analysis and flow cytometry. For image analysis, Feulgen-stained slides of tumor imprints and of disaggregated tumor cytospin preparations were evaluated with the CAS-200 image analyzer. For flow cytometry, propidium iodide-stained disaggregated tumor cells were analyzed with the Coulter EPICS-C flow cytometer. The two methods yielded comparable results. The DNA indices obtained by the two methods showed close correlation by linear regression analysis (r = 0.86, P less than 0.001). There were 26 diploid (52%) and 24 nondiploid (48%) carcinomas. The ploidy pattern between the two methods showed agreement in 41 carcinomas (82%) and discordance in two (4%). Three tumors (6%) were equivocal by flow cytometry and four (8%) by image analysis. The equivocal cases presented potential sources of error in the evaluation of histograms in the near-tetraploid region by flow cytometry and in the near-diploid region by image analysis. Image analysis required smaller tissue samples and permitted direct visualization and selection of tumor cells. It also detected more tetraploid carcinomas. In contrast, flow cytometry analyzed larger cell samples and provided histograms with better resolution. It more readily detected the presence of multiple aneuploid peaks and also the presence of aneuploid peaks in the near-diploid range. The presence of aneuploidy was significantly related to the loss of hormone receptor expression, high mitotic rate, and high histologic and nuclear grades. Our study indicates that image analysis and flow cytometry provide comparable results in a majority of breast carcinomas.(ABSTRACT TRUNCATED AT 250 WORDS)