Dietary pattern, food, and nutritional supplement effects on cognitive outcomes in mild cognitive impairment: a systematic review of previous reviews

CONTEXT

Nutritional interventions may benefit cognition in people with mild cognitive impairment (MCI). However, evidence is yet to be synthesized in a way that can inform recommendations for clinical and public health settings.

OBJECTIVE

To systematically review evidence on the effect of dietary patterns, foods, and nutritional supplements on cognitive decline in individuals with MCI.

DATA SOURCES

Guided by the Preferred Reporting items for Systematic Review and Meta-Analysis Protocols 2015 statement, the Medline, EMBASE, and CINAHL databases, the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects were searched (publication years 2005 to 2020). Included studies were English-language systematic reviews and meta-analyses of randomized controlled trials and cohort studies reporting on the effectiveness of nutritional interventions on cognition of individuals with MCI.

DATA EXTRACTION

Two reviewers independently selected studies and extracted data on cognitive outcomes and adverse events. Review quality was assessed using AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews-2). Primary study overlap was managed following Cochrane Handbook guidelines.

DATA ANALYSIS

Of the 6677 records retrieved, 20 reviews were included, which, in turn, reported on 43 randomized controlled trials and 1 cohort study that, together, addressed 18 nutritional interventions. Most reviews were limited by quality and the small number of primary studies with small sample sizes. Reviews were mostly positive for B vitamins, omega-3 fatty acids, and probiotics (including 12, 11 and 4 primary studies, respectively). Souvenaid and the Mediterranean diet reduced cognitive decline or Alzheimer's disease progression in single trials with <500 participants. Findings from studies with a small number of participants suggest vitamin D, a low-carbohydrate diet, medium-chain triglycerides, blueberries, grape juice, cocoa flavanols, and Brazil nuts may improve individual cognitive subdomains, but more studies are needed.

CONCLUSIONS

Few nutritional interventions were found to convincingly improve cognition of individuals with MCI. More high-quality research in MCI populations is required to determine if nutritional treatments improve cognition and/or reduce progression to dementia.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework protocol identifier DOI:10.17605/OSF.IO/BEP2S.

First reported human bloodstream infection with Vagococcus lutrae

Vagococcus lutrae belongs to the Vagococcus genus; it is possible to isolate vagococci from marine hosts, contaminated food and soil. To our knowledge, this is the first case of bloodstream infection with V. lutrae and only the second reported human infection in the literature. As in the first reported case of clinical infection with V. lutrae, this woman had several wounds. The clinical investigation showed no other foci for the bloodstream infection, so we hypothesize that the wounds were colonized, although they showed no signs of infection and skin swabs did not reveal V. lutrae.

Design of a novel digital intervention to promote healthy weight management among postpartum African American women

BACKGROUND

Excess weight retention among postpartum women is a risk factor for long term obesity, and African American women are at heightened risk. New solutions, including digital technologies and community-based approaches are needed. Digital platforms, like social media, provide opportunity for participant co-creation (i.e., content co-generated by users and investigators) of health messages and may allow for adaptation of evidence-based weight management interventions to reduce participant burden. The BeFAB intervention, a branded, digital weight management program, tests this hypothesis.

METHODS

BeFAB content comprises culturally-specific nutrition, physical activity, stress management, health information seeking and related weight management messages and content designed for African American women. The intervention is 12 weeks in duration, delivered through a mobile phone app, and is designed to target specific behavioral predictor beliefs and attitudinal measures (e.g., self-efficacy to achieve weight management goals) based on the culturally-specific content. Use of personal, culturally-specific video-based narratives in the app, and through a secret Facebook group, are included to help model HEAL behaviors and brand BeFAB. Intervention development consisted of iterative formative research steps to engage African American women. The program will be evaluated in a small randomized trial among patients recruited at a clinical facility.

CONCLUSIONS

BeFAB applies evidence-based content using a promising digital approach. It is novel in its use of branding, culturally-tailored content, and digital technology for behavior change.Evaluation of BeFAB will contribute to the growing literature on digital health behavior change interventions for weight management.

Does the working temperature affect the outcome following microwave endometrial ablation?

BACKGROUND

Menorrhagia is a common gynaecological complaint, with significant burden to both its sufferers and health service providers. The first line of treatment is usually medical/pharmaceutical although in some cases surgery is required. There are now a number of minimally invasive surgical techniques available that ablate the uterine lining and prevent the need for the removal of the uterus. Microwave endometrial ablation (MEA) is one of these techniques, and this paper investigates the effect of the working temperature on outcome.

METHODS

A retrospective case note review of women who underwent MEA between June 2000 and August 2004. All women had a hysteroscopy followed by MEA. The duration of the procedure and mean working temperature of the MEA treatment was calculated. Women were followed up 6-8 months after surgery.

FINDINGS

Two hundred and eleven women underwent the procedure, with an average duration of menorrhagia of 30 months prior to the procedure. Eighty-nine percent attended follow-up, 80 % were satisfied with the procedure and 40 % were amenorrhoeic. When the procedure was performed at higher working temperature within the manufacturers guidelines women were more likely to be amenorrhoeic (78.4 vs. 77.1 °C, p = 0.014).

CONCLUSION

MEA is more effective in treating menorrhagia when used at a higher operating temperature.

Continuous infusion of local anaesthetic following laparoscopic hysterectomy--a randomised controlled trial

OBJECTIVE

To estimate whether a continuous infusion of intraperitoneal local anaesthetic for 48 hours following laparoscopic hysterectomy reduced the need for opioids delivered with a patient-controlled analgesia pump.

DESIGN

Double-blind randomised placebo-controlled trial.

SETTING

District general hospital in the UK.

POPULATION

Women undergoing a laparoscopic hysterectomy for a benign indication.

METHODS

Women were randomised to receive either 0.5% levobupivicaine or 0.9% normal saline via an ON-Q elastomeric pump for 48 hours postoperatively. The amount of opioids used via the patient-controlled analgesia pump was recorded and pain was measured using an 11-point Box Scale.

MAIN OUTCOME MEASURES

The primary outcome was the amount of patient-administered morphine used over the first 48 postoperative hours. Secondary outcomes were length of hospital stay, oral analgesia use and level of patient-reported pain.

RESULTS

Sixty women participated and completed the trial. There was no difference (P = 0.59) in the median amount of patient-administered morphine used between the levobupivicaine (23 mg) and placebo (18.5 mg) groups; median group difference 3.0 (95% CI -7.0 to 14.0). There was also no difference in the length of hospital stay with 40% of the treatment group remaining in hospital >48 hours compared with 30% of the placebo group (P = 0.08). Pain scores at all postoperative time points remained similar, with a median group difference in pain scores of 1.0 (95% CI -1.0 to 2.0) at the end of the first postoperative day.

CONCLUSIONS

Continuous infusion of 0.5% levobupivicaine into the peritoneal cavity following laparoscopic hysterectomy does not have any opioid-sparing effects.

Necrobiotic xanthogranuloma with paraproteinaemia

Necrobiotic xanthogranuloma is a rare cutaneous condition that can be mistaken for atypical necrobiosis lipoidica. It has a strong association with a paraproteinaemia, which may progress to frank haematological malignancy. We describe four patients with variable cutaneous features, and their treatment response.

Religiosity and attitudes about abortion

In a sample of 55 undergraduates, religiosity scores were associated with more restrictive attitudes toward abortion.

Serum total sialic acid, a reputed cardiovascular risk factor, and its relationship to lipids, plasma fasting insulin, blood pressure and body mass index in normal individuals

1. Serum sialic acid is a reputed cardiovascular risk factor, but the reason why this is so is not clear. We therefore studied its relationship with other known cardiovascular risk factors (particularly those associated with insulin resistance) in 100 healthy young subjects (54 females and 46 males, age 20.7+/-0.89 years). 2. There was a significant univariate correlation between serum total sialic acid and fasting plasma insulin. Serum total sialic acid also correlated with fasting plasma glucose concentration and serum cholesterol and triacylglycerol. 3. In females there was a strong univariate correlation between serum total sialic acid and plasma fasting insulin and glucose concentrations, although in males there was a weaker univariate correlation between serum total sialic acid and fasting plasma glucose and the insulin resistance index. In addition, serum total sialic acid significantly correlated with systolic blood pressure, fasting serum cholesterol and triacylglycerol concentrations and body mass index in the females. In males serum total sialic acid significantly positively correlated with fasting serum cholesterol and triacylglycerol concentrations, and correlated inversely with the hip/waist ratio. 4. In multiple regression analysis of the 100 subjects serum total sialic acid correlated independently with fasting serum cholesterol, glucose and also plasma insulin concentrations. In females serum total sialic acid independently correlated with systolic and diastolic blood pressure, and serum cholesterol and fasting plasma glucose concentrations, although there was no significant independent correlation between serum total sialic acid and any of the other variables in the males.

Serum sialic acid, a reputed cardiovascular risk factor, is elevated in South Asian men compared to European men

Serum total sialic acid (TSA) has recently been reported as a cardiovascular risk factor, but whether there are racial differences is not known. One hundred and twenty-four healthy young subjects (62 women and 62 men) were studied. Their age was 20.7 [0.9] years and they were matched for body mass index (BMI). Sixty-eight were of South Asian origin (37 women and 31 men) and 56 (25 women and 31 men) were European. Mean (SD) serum TSA was significantly higher in the South Asian men than the age-matched European men (74.3 [12.3] mg/dL versus 68.2 [13.0] mg/dL, P = 0.0198). In addition, serum TSA was significantly higher in South Asian women compared with European men (71.6 [8.9] mg/dL versus 68.2 [13.0] mg/dL, P = 0.0352). Finally, serum TSA was significantly higher in European women compared with European men (76.0 [13.1] mg/dL versus 69.2 [13.0] mg/dL, P = 0.008). We conclude that serum TSA may be worth measuring in different racial groups and also may be useful to assess individuals at risk of cardiovascular disease. Large prospective studies may help to explain why serum TSA is a reputed cardiovascular risk factor and shows racial differences.

Hepatitis B core antigen antibody as an indicator of a low grade carrier state for hepatitis B virus in a Saudi Arabian blood donor population

Blood donor screening for anti-hepatitis B core antigen (anti-HBc) was introduced as a surrogate marker of non-A, non-B hepatitis prior to the availability of a specific test for hepatitis C. In areas endemic for hepatitis B virus (HBV), such as Saudi Arabia, earlier studies indicated that up to 30% of blood donors might disqualify if screened for anti-HBc. The issue was readdressed in a study of 6035 consecutive first-time Saudi national blood donors in an attempt to identify a subgroup of anti-HBc positive donors who might be at high risk of being low grade carriers of HBV. An isolated anti-HBc of high titer in a donor with a low or absent anti-hepatitis B surface antigen (anti-HBsAg) was taken as an indicator of increased risk of a low grade carrier state. Using this algorithm, an additional 125 (2%) donors would disqualify. HBsAg immune complex assays and polymerase chain reaction of donor samples with an isolated anti-HBc identified two donors with immune complexes and two donors with HBV DNA. All four donor samples expressed over 90% neutralization in the anti-HBc supplementary testing, indicating high titer anti-HBc. These findings seem to support the suggested policy of donor exclusion based on the anti-HBc and anti-HBsAg serology as a means to eliminate low grade carriers of HBV in endemic areas without jeopardizing the blood supply.

International forum: Saudi Arabia. Donor screening for HTLV-I in Saudi Arabia: is it cost effective?

After screening over 100,000 blood donations for the presence of anti-HTLV-I antibodies, a final prevalence of 0.0038% was established in a multinational donor population. Among 38,201 donations by Saudi Arabian donors, the prevalence was found to be 0.0052%. Fifty-eight donors were found to be repeat reactive in the EIA screen test, but only 6.9% of these (n = 4) were truly infected with HTLV-I as judged by the Western blot result. These results indicate that Saudi Arabia is non-endemic for HTLV-I as well as HTLV-II. The cost effectiveness of screening for HTLV-I in healthy blood donors from this area is highly questionable. Calculations point to a final risk of a case of post-transfusion HTLV-I associated disease of approximately one per 100 years at the current level of activity.

Control of microbial contamination in unpreserved eyedrops

AIMS/BACKGROUND

Preservatives are added to multidose eyedrop containers to ensure that the eyedrops do not become heavily contaminated during patient use. This enables eyedrops to be used for up to 1 month after opening. However, patients are frequently required to use unpreserved eyedrops as their eyes are unable to tolerate these preservatives. Some commercial unpreserved unit dose eyedrops are available, but the range is limited, and they cannot be used in all cases. Twenty one different unpreserved eyedrop formulations in multidose bottles were tested to establish their inherent efficacy in antimicrobial preservation, and to help determine a suitable in use storage life.

METHODS

The eyedrops were inoculated with a known quantity of four different micro-organisms according to the method of the European Pharmacopoeia 'Test for the efficacy of antimicrobial preservation'. After set periods of time, samples were taken to determine the number of viable organisms remaining.

RESULTS

Antibiotics and alkaloids were generally shown to have higher kill rates than other eyedrops such as artificial tears and steroids.

CONCLUSIONS

In general, once opened by individual patients in a domiciliary situation, a 7 day in use storage life is confirmed for eyedrops containing alkaloids or antibiotics, if they are stored in the refrigerator after opening.

Antibiotic treatment of ophthalmic infection: new developments

The introduction of quinolones has dramatically altered antibiotic therapy for serious ophthalmic infections. The newer cephalosporins are also playing a more significant role. The recently introduced macrolides, particularly azithromycin, have great potential for treating not only serious infections, but also some of the less serious ones. These new developments are discussed, and the cost implications of new antibiotic treatment on ophthalmology is described.

Ethnic differences in stroke mortality between non-Hispanic whites, Hispanic whites, and blacks. The National Longitudinal Mortality Study

BACKGROUND AND PURPOSE

Although US blacks are known to have an excess stroke mortality compared with US whites, little is known about the stroke burden of the Hispanic white population. This report will provide estimates of the relative burden of stroke mortality in the US black and Hispanic population relative to the white population and examine the consistency of this relation across age.

METHODS

Data were from participants aged > 45 years from the National Longitudinal Mortality Study. There were 1844 stroke deaths among 239,734 non-Hispanic whites, 46 deaths among 12,527 Hispanic whites, and 234 deaths among 23,468 black participants. Standard statistical methods were used to examine the ethnic differences in stroke mortality.

RESULTS

The hazard ratios for black men and women (relative to non-Hispanic whites) were nearly identical, at > 4.0 at age 45 but marginally < 1.0 by age 85. For both Hispanic men and women, the hazard ratios (relative to non-Hispanic whites) were approximately 1.0 at age 45 but were marginally significantly < 1.0 at older ages. The ethnic differences in stroke death rates reveal differences in age distributions of age at fatal stroke between these groups. Approximately 6% of fatal strokes for non-Hispanic whites occurred before age 60, whereas > 15% occurred in both Hispanic whites and blacks.

CONCLUSIONS

These results suggest that (1) for Hispanics, stroke risk is similar to that for non-Hispanic whites at young ages but is marginally lower at older ages, (2) the excess stroke mortality in blacks mainly occurs at younger ages (between 45 and 55 years), and (3) the relation between stroke risk for blacks and Hispanics relative to whites is similar by sex. The impact of age on relative stroke mortality would argue against simple age adjustment for describing ethnic differences in stroke mortality. Finally, proportionally, more strokes occur at older ages in non-Hispanic whites than in either US blacks or Hispanic whites.

Secondary cytokine production by lymphoid cells used in cellular immunotherapy

Interleukin-2 (IL-2) has been used extensively in cellular immunotherapy trials as a systemic activator of the immune system as well as an ex vivo stimulant for lymphoid cell function. Despite the measurement of several in vitro and in vivo immunologic parameters related to cellular immunotherapy, determinants of successful cellular immunotherapy remain unknown. To further delineate the consequences of exposing peripheral blood lymphocytes to high concentrations of IL-2, we assessed the supernatants of IL-2-activated peripheral blood lymphocytes for production of tumour necrosis factor (TNF) and interferon-gamma (IFN-gamma). Exposure of normal monocyte-depleted peripheral blood mononuclear cells (PBMC) to IL-2 caused a dose-dependent increase in secretion of TNF and IFN-gamma which increased linearly after 48 h in culture. Analysis of positively selected, highly purified PBMC subpopulations exposed to IL-2 revealed that TNF-alpha and TNF-beta were produced by both CD3+ and CD16+ subpopulations but not by CD22+ cells. These studies were extended to supernatants obtained from PBMC cultures used in the adoptive cellular immunotherapy of patients with advanced cancer. Patients treated with lymphokine-activated killer (LAK) cell immunotherapy were classified as responders (N = 14) or non-responders (N = 17) to therapy. We found no significant difference in the production of TNF between responders and nonresponders (22 +/- 9 U ml-1 vs. 20 +/- 6 U ml-1), P > 0.05. However, LAK cell supernatants harvested from non-responders contained a significantly higher level of IFN-gamma (232 +/- 94 U ml-1) compared with responders (42 +/- 14), P < 0.05. Furthermore, the linear association between IFN-gamma and TNF-alpha production was different between these two response groups (rs = -0.19 for non-responders and rs = 0.48 for responders). These results suggest that secondary cytokine production by adoptively transferred lymphocytesmay play an important role in the host response to cellular immunotherapy.

A centromere map of the X chromosome from trisomies of maternal origin

A centromere map is derived from XXX and XXY trisomies of maternal origin. Preliminary data suggest reduced recombination in the tetrads giving rise to mei I nondisjunction, but an excess of recombination in the pericentric region. As in Drosophila, multichiasmate tetrads may be more at risk of nondisjunction than nullochiasmate tetrads.

MAP, an expert system for multiple pairwise linkage analysis

The logic of a program for multiple pairwise linkage analysis under interference is set forth, including a seriation algorithm to obtain a trial order, a mapping bootstrap to improve the trial order, and three procedures for quality control to detect mistyping. This approach is compared with multipoint analysis under null interference, which substantially overestimates map length and cannot incorporate a variety of data.

Methylcellulose for endothelial cell protection

A randomised trial of three types of endothelial cell protection for patients undergoing posterior chamber intraocular lens implant is described. The results confirm the superiority of a viscoelastic fluid over air as a form of endothelial cell protection. No statistically significant difference was found between sodium hyaluronate and hydroxypropylmethylcellulose (HPMC). As the cost of sodium hyaluronate is prohibitive, a manufacturing technique for HPMC is given.

The differential effects of inductions of worry, somatic anxiety, and depression on emotional experience

One-hundred and twenty-eight subjects underwent inductions of emotions designed to elicit worrisome, depressed, somatically anxious, or neutral emotional states, and then they completed the Multiple Affect Adjective Checklist. Induction of worry was found to produce (a) moderate degrees of both anxiety and depression, (b) emotional profiles more highly correlated with those of depression and somatic anxiety than the correlation of depression and somatic anxiety profiles with each other, and (c) a subjective state containing no unique emotional features separate from that induced in depression and somatic anxiety. Whereas a discriminant function analysis correctly classified 70-85% of the subjects in the other three conditions, subjects who underwent the induction of worry were correctly classified at only chance level.

The significance of pancytopenia in miliary tuberculosis

Patients with miliary tuberculosis accompanied by a pancytopenia rarely survive their disease. If the peripheral blood picture does recover it has been taken as an indication that there is no underlying haematological disease, and so re-examination of the bone marrow is not performed. A case is described where resolution of the pancytopenia occurred but a persisting haematological disease remained. Aspects of haematological disease associated with tuberculosis are discussed.

Association between azathioprine therapy and lymphoma in rheumatoid disease

Three out of 41 patients treated with azathioprine and low-dose corticosteroids from 1976 to 1983 developed non-Hodgkin's lymphoma. This strikingly high incidence of lymphoma may be a reflection of long-term use of azathioprine.

Air, methylcellulose, sodium hyaluronate and the corneal endothelium. Endothelial protective agents

In a randomised trial the endothelial protective agent used during extracapsular cataract extraction and intraocular lens insertion was air in 19 eyes (group 1), methylcellulose in 25 eyes (group 2) and sodium hyaluronate in 22 (group 3). The cell population densities of each eye were estimated immediately before and three months after the operations to determine the degree of cell loss. Eyes showing mechanical (touch) damage on the second postoperative day were eliminated. The numbers of eyes in each group which showed a statistically significant cell loss were compared, and the mean cell losses in each group were tested for significant differences. It appears that air actually damages the endothelium while methylcellulose and Na-hyaluronate are not harmful, and afford a high, essentially equal degree of endothelial protection.

Pharmacokinetics and hemodynamics of amrinone in patients with chronic cardiac failure of diverse etiology

The pharmacokinetics of amrinone and its relationship to ventricular function were assessed in 15 patients with chronic cardiac failure following the administration of a single 100 mg oral dose. Patients examined had Class II (1 patient), Class III (13 patients) and Class IV (1 patient) heart failure as characterized by the New York Heart Association classification. Blood samples were obtained following amrinone administration at selected times for 8 hours following the dose. Cardiac output was assessed serially for 5 hours following amrinone dosing. Mean (SD) peak plasma concentrations of amrinone (2.1 (1.1) mcg/ml) were obtained 0.5 to 2 hours after drug administration. The mean (SD) apparent oral clearance, apparent volume of distribution at steady state and half-life of amrinone were 0.23 (0.13) L/hr/kg, 1.2 (0.4) L/kg, and 4.8 (3.0) hr. Peak increases in cardiac index averaged 50% of baseline values and improvement was maintained at least 5 hours following amrinone dosing when compared to baseline cardiac index (p less than 0.05). Examination of the relationship between cardiac index corrected for baseline and amrinone plasma concentrations within individuals yielded strong and highly significant relationships (r greater than 0.90; p less than 0.025) in five patients, while in the remaining patients, either no relationship existed or insufficient data was available for analysis. When the data from all patients were pooled, a modest though significant relationship (r = 0.67; p less than 0.01) existed between cardiac index corrected for baseline and the post-absorptive, post-distributive amrinone plasma concentration. No difference in response to amrinone as a function of failure etiology or functional aerobic capacity was evident. Evaluation of the relationships between the mean improvement in cardiac index versus amrinone plasma concentration, as well as the time courses of these parameters indicate that the site of action of amrinone may be pharmacokinetically distinguishable from plasma and the tissues in instantaneous equilibrium with plasma.

Is topical haloperidol a useful glaucoma treatment?

A randomised, double blind, single dose study of topical haloperidol, a dopamine receptor blocking drug, was performed on 20 healthy volunteers. After its administration a modest reduction in intraocular pressure was recorded over the six-hour study period, but the difference was not significant at the p less than 0.05 level. Although dopamine blocking agents are effective in reducing intraocular pressure in experimental animals, topical haloperidol appears unlikely to be clinically useful in the treatment of glaucoma.

Milrinone in the treatment of chronic cardiac failure: a controlled trial

This study examines the acute hemodynamic response to intravenous and oral milrinone in 12 patients with moderate to moderately severe heart failure. The patients received milrinone or placebo at random in an 8-week double-blind trial. Dosing level and schedule were determined by the hemodynamic results. Acute and chronic plasma samples for milrinone concentration were drawn from patients throughout the study. Milrinone was administered intravenously in successive doses of 25, 50, and 75 micrograms/kg. This resulted in a 16.5%, 12.5%, and 28.4% peak increase in cardiac index, with a concomitant 24%, 29%, and 38% decrease in pulmonary capillary wedge pressure. There were no significant relationships between any of the mean maximal hemodynamic values and milrinone plasma concentration. Six patients received milrinone and six patients received placebo; only five patients completed the blinded phase. There was no significant difference between the groups in exercise capacity, but the conditions of five of the six patients who received placebo deteriorated. In two of the patients who received milrinone the aerobic capacity improved greater than 2 cc/min/kg over baseline, and an additional two patients reported a marked subjective improvement. The results of this study indicate that oral milrinone in the management of patients with chronic cardiac failure would justify larger controlled studies.

Amrinone in the treatment of chronic cardiac failure

The efficacy and safety of oral amrinone were examined in 17 patients with moderately severe to severe heart failure that was refractory to standard medical therapy and vasodilators. The short-term and 28 week response to open amrinone therapy was assessed first, followed by a placebo-controlled, double-blind withdrawal study of two 13 week stages in nine patients. Rest and exercise ventricular function were determined before and after 32 hours of amrinone; aerobic capacity was serially assessed. After 2 hours, 1.64 mg/kg amrinone produced a 40% (p less than 0.001) increase in cardiac output and a 32% (p less than 0.02) decrease in pulmonary wedge pressure without altering heart rate or blood pressure. The exercise cardiac index-wedge pressure curve obtained 32 hours after the first oral dose was significantly shifted (p less than 0.05) above control values. A sustained improvement in maximal oxygen uptake was noted during long-term open amrinone therapy. Subsequently, seven of the patients randomized to placebo therapy had a significant deterioration of symptoms or exercise tolerance, or both. After 4 weeks of readministration of amrinone, clinical stability was once again established and exercise tolerance was improved by Weeks 8 to 16. Adverse effects of thrombocytopenia (one patient) and hepatic dysfunction (one patient) attributable to amrinone were observed. It is concluded that amrinone is effective in the long-term treatment of chronic cardiac failure.

On the standard error of the probability of a particular diagnosis

Approximate standard errors of the probability of a particular diagnosis are given for the predictive and estimative methods described by Aitchison and Dunsmore. An example used in the detection of carriers of Duchenne muscular dystrophy (DMD) is given for illustration.

Pirbuterol, an oral beta-adrenergic receptor agonist, in the treatment of chronic cardiac failure

Pirbuterol (PB), an oral beta-adrenergic-receptor agonist, has the pharmacologic effects of vasodilation and positive inotropy. The present studies were undertaken to determine the value of PB in the long-term therapy of chronic cardiac failure. A double-blind, randomized, 7-week trial comparing PB (20 mg three times daily) with placebo in 12 patients was followed by 12 weeks of open PB therapy. Dose-dependent nervousness and tremulousness limited the unit PB dose to less than 20 mg in six patients. In all patients, clinical status, exercise tolerance and maximal oxygen uptake, left ventricular echocardiographic dimension and cardiothoracic ratio were unchanged from control after 7 weeks of placebo or PB or after 12--19 weeks of PB. To assess the adequacy of 20 mg of PB, the dose-response relations of cardiocirculatory effects to 10, 15, 20 and 30 mg of PB were compared in seven of the above patients and nine other patients. Cardiac output was significantly elevated and wedge pressure reduced after all four doses, but these changes were sustained from 6 hours after 20- and 30-mg doses only. Thus, the role of PB in the management of chronic cardiac failure appears limited; judgment of its utility must await the results of additional controlled trials.

Cardiotonic agents in the management of chronic cardiac failure

Heart failure is a syndrome with distinct clinical signs and symptoms. The severity of cardiac failure and a deterioration in functional capacity can be determined by a progressive exercise test and by the noninvasive determination of maximum oxygen uptake. In patients with severe cardiac failure refractory to medica therapy, particularly those with cardiomyopathy or ischemic heart disease, survival is seriously compromised, resembling the most serious malignancy. Cardiotonic agents may be useful in improving the quality of life, provided that they are effective and are given sufficiently early in the course of the disease. Dobutamine given intravenously augments cardiac performance and improves renal function in patients with very advanced disease refractory to multiple diuretics; long-term survival, however, remains dismal. Amrinone appears to be a promising agent for the long-term treatment of chronic cardiac failure; the utility of pirbuterol, an oral catecholamine analog, remains to be determined.

Vasodilator and inotropic agents in treatment of chronic cardiac failure: clinical experience and response in exercise performance

The sensations of breathlessness and fatigue limit the capacity of patients with chronic congestive cardiac failure (CHF) to participate in physical activities. As a result, patients with CHF gauge quality of life in terms of symptom-free activities they can undertake. Physicians attempt to alleviate these limiting symptoms and increase the exercise capacity of patients with CHF by therapeutic interventions. In recent years a variety of systemic vasodilators and inotropic agents have been introduced to aid digitalis and diuretics in improving cardiac performance in patients with CHF. Although the pumping function of the heart is enhanced at rest, it remains to be determined whether exercise tolerance is also improved. In this paper we review our clinical experience with a number of systemic vasodilators and positive inotropic agents, focusing particular attention on their influence on exercise performance in patients with CHF. This experience includes (1) 28-week double-blind study of hydralazine vs placebo in 19 patients with CHF, (2) 52-week double-blind crossover study of trimazosin (alpha 1 blockade) vs placebo in 27 patients with CHF of varying severity, and (3) open study of amrinone (positive inotropic agent) in 12 patients with CHF.

Increase in leg blood-flow by normovolaemic haemodilution in intermittent claudication

Normovolaemic haemodilution down to a packed-cell volume of 35% was done in 10 patients with stable intermittent claudication. For a mean reducation in the packed-cell volume of 21.5% there was a 170% increase in peak calf blood-flow and a 111% increase in haemoglobin delivery. 7 of the 10 patients reported an increased walking distance. Normovolaemic haemodilution may be of use in the management of some patients with peripheral vascular disease.