Comparison of vasopeptidase inhibitor, omapatrilat, and lisinopril on exercise tolerance and morbidity in patients with heart failure: IMPRESS randomised trial

BACKGROUND

We aimed to assess in patients with congestive heart failure whether dual inhibition of neutral endopeptidase and angiotensin-converting enzyme (ACE) with the vasopeptidase inhibitor omapatrilat is better than ACE inhibition alone with lisinopril on functional capacity and clinical outcome.

METHODS

We did a prospective, randomised, double-blind, parallel trial of 573 patients with New York Heart Association (NYHA) class II-IV congestive heart failure, left-ventricular ejection fraction of 40% or less, and receiving an ACE inhibitor. Patients were randomly assigned omapatrilat at a daily target dose of 40 mg (n=289) or lisinopril at a daily target dose of 20 mg (n=284) for 24 weeks. The primary endpoint was improvement in maximum exercise treadmill test (ETT) at week 12. Secondary endpoints included death and comorbid events indicative of worsening heart failure.

FINDINGS

Week 12 ETT increased similarly in the omapatrilat and lisinopril groups (24 vs 31 s, p=0.45). The two drugs were fairly well tolerated, but there were fewer cardiovascular-system serious adverse events in the omapatrilat group than in the lisinopril group (20 [7%] vs 34 [12%], p=0.04). There was a suggestive trend in favour of omapatrilat on the combined endpoint of death or admission for worsening heart failure (p=0.052; hazard ratio 0.53 [95% CI 0.27-1.02]) and a significant benefit of omapatrilat in the composite of death, admission, or discontinuation of study treatment for worsening heart failure (p=0.035; 0.52 [0.28-0.96]). Omapatrilat improved NYHA class more than lisinopril in patients who had NYHA class III and IV (p=0.035), but not if patients with NYHA class II were included.

INTERPRETATION

Our findings suggest that omapatrilat could have some advantages over lisinopril in the treatment of patients with congestive heart failure. Thus use of vasopeptidase inhibitors could constitute a potentially important treatment for further improving the prognosis and well being of patients with this disorder.

Ascorbic acid is neuroprotective against global ischaemia in striatum but not hippocampus: histological and voltammetric data

Following reports that ascorbic acid (AA) blocks NMDA receptors, we examined its possible neuroprotective properties in vivo (gerbil bilateral carotid artery occlusion model: BCAO) and in vitro (ischaemia-induced dopamine (DA) release in brain slices). Five minutes of BCAO caused substantial cell loss of 90-95% and 40-50% in gerbil CA1 hippocampus and striatum, respectively, measured in haematoxylin and eosin-stained sections, 5 days post-insult. AA (500 mg kg(-1) day(-1) i.p. for 312 days, first dose 1 h before occlusion) significantly (P<0.05) reduced striatal cell loss (from 40 to 13%) while only reducing CA1 cell loss from 95 to 88%. A lower dose (250 mg kg(-1) day(-1) i.p. for 312 days) was ineffective in either region. AA (750 mg kg(-1) day(-1) i.p. for 312 days) caused significant striatal protection (cell loss reduced from 49 to 20%) if treatment was initiated 1 h before occlusion. Initiation of treatment immediately post occlusion did not cause significant protection. Neither treatment regime protected CA1 hippocampus. In separate experiments we examined the effect of AA on DA release, monitored by voltammetry, in an in vitro model of striatal ischaemia. Four DA release variables were measured: T(on)--time from initiation of ischaemia to the onset of DA release, T(pk)--the time from onset of DA release to maximum, deltaDA/deltat--the mean rate of DA release and [DA](max)-- the maximum extracellular DA concentration. Control values in drug-naive slices were: T(on)=193+/-8 s, T(pk) = 24 +/- 4 s, [DA](max) = 69 +/- 6 microM and deltaDA/deltat = 4.2 +/- 0.7 microM s(-1) (means+/-S.E.M., n=15). 212 h pretreatment with AA (0.4 to 10 mM) did not affect T(on) or [DA](max) but increased T(pk) and decreased deltaDA/deltat (P<0.05) with an EC50 of 1.66 mM. NMDA (100 microM) shortened T(on). N-ethylmaleimide (20 microM) had no effect on the response to AA but potentiated the action of NMDA on T(on). AA (2 or 10 mM) had no effect on the response to NMDA. We conclude that AA is neuroprotective against global ischaemia in the striatum and that some of this action may be due to attenuation of ischaemia-induced DA release. This action is mediated neither by blockade of the NMDA receptor nor modulation of its redox status.

Metastatic melanoma to the heart presenting with ventricular tachycardia

Intraventricular tumors in adults are uncommon, and the association of these with ventricular tachycardia is even more rare. We report a case of an intracardiac metastatic melanoma in a woman who presented with syncope due to ventricular tachycardia.

Estimating the feeding rate of the bedbug Cimex lectularius in an infested room: an inexpensive method and a case study

The common bedbug, Cimex lectularius L. (Hemiptera: Cimicidae), is a globally re-emerging pest that is playing an increasing role in legal disputes and compensation claims as a result of its unpleasant feeding activity. However, there is little information about the feeding frequency of bedbugs outside controlled laboratory cultures. Here, we present a simple method of estimating the average time since the last bloodmeal of individual female bedbugs in a single sampling event, applicable to a single bedbug harbourage or an entire room. Using the temperature-dependent rate of decrease in the abdomen size of the bedbug after a bloodmeal, we found that, in a highly infested room kept at a constant temperature of 26 degrees C, females fed every 2.5 days on average. Our method corrects for variations in body size across different populations and determines the shrinkage that occurs when individuals are preserved in ethanol. This method should, therefore, be widely applicable. It is cheap, rapid and, if coupled with information on the total number of bedbugs present in a room, allows for the estimation of the minimum number of times persons lodging in a room have been bitten by bedbugs. This method can also be used to calculate the feeding rate of other blood-sucking insects on their hosts. The sex ratio in the infestation was female-biased. Finally, our case study suggests that individual female bedbugs within a harbourage do not seem to feed at a regular rate, but tend to synchronize feeding patterns.

Failure of immunotherapy to prevent, arrest or reverse diabetic lumbosacral plexopathy

Three patients are described who had severe and progressive diabetic lumbosacral plexopathy despite active immunosuppressive therapy. One patient developed the condition while immunosuppressed for a cardiac transplant and two others progressed while receiving intravenous gamma globulin. The cases raise questions about current unsupported practices of treatment for this condition. Robust clinical trial evidence is required before immunosuppression can be recommended.

Qualitative Analysis of Pediatric Patient and Caregiver Perspectives After Recent Diagnosis With Inflammatory Bowel Disease

PURPOSE

A diagnosis of a chronic illness is a life-altering experience for a child and his or her family. The purpose of this study was to elicit children and parent perspectives following a diagnosis of Inflammatory Bowel Disease (IBD).

DESIGN & METHODS

A qualitative description design was employed. Eighteen patients were recruited from a Pediatric IBD Clinic in Western Canada. Interviews were used to gather perceptions, opinions, and attitudes from children and their parents. Transcriptions of the interviews were analyzed using a qualitative content analysis.

RESULTS

Four themes were identified: perspective of diagnosis, roles in care and decision-making, sharing the diagnosis, and treating the disease. Children and parents expressed varied emotions in response to diagnosis. Families articulated the desire to become more active members in the decision-making process on treatment choices. While using conventional medical therapy was seen as an appropriate choice for short-term therapy, many parents hoped that more non-conventional and alternative therapies could be used in the future.

CONCLUSION

Healthcare providers need to provide excellent education on the disease process, treatment options, and the use of CAM therapy in IBD, while at the same time supporting children and parent's voices in treatment decisions.

PRACTICE IMPLICATIONS

Improvement strategies need to be implemented to allow families to feel that they have a voice when making decisions regarding treatment options. Families need to be educated and supported on the use of CAM therapies in IBD.

Child safety education and the world wide web: an evaluation of the content and quality of online resources

The purpose of this study was to assess the content, quality, and type of internet resources available for safety education. Using 19 search engines with search strings targeting major forms of injury, identified resources were classified by audience group, accessibility, and authorship. Two independent reviewers rated each resource on the basis of its content and a set of quality criteria using a three point scale. Overall, 10 (18.2%) resources were of highest quality, four (7.3%) were intermediate, and 41 (74.5%) were not recommended. Eighteen months after the original search, 67.3% of all resources and 90% of the highest quality resources were still on the internet. This study provides a methodology for evaluating child safety resources on the world wide web and demonstrates that most internet resources for safety education are of dubious quality. A rating system such as the one developed for this study may be used to identify valuable internet materials.

The crystal structure of Bis(benzothiazole-2-thiolato)bis(pyridine)cobalt(II)

Crystalline bis(benzothiazole-2-thiolato)bis(pyridine)cobalt(II) [Co(mbt)2(py)2] contains molecular complexes with C2 point symmetry, in which the cobalt is coordinated by two thiazole nitrogen atoms[cis, Co- N = 2.158(4) Ǻ], two mbt- exocyclic sulphur (Se) atoms [trans, Co-S = 2.595(5) Ǻ],and two pyridine nitrogen atoms [cis, Co-N = 2.120(4) Ǻ]. The N-C-S, section of mbt- is loosely coordinated to cobalt, forming a four-membered chelate ring. It is inferred from the observed dimensions that the electronic structure of coordinated mbt- is ?allylic?, N=C=Se. The crystals are orthorhombic, a 16.165(1), b 16.302(1), c 18.533(1) , Ǻ, space group Pccn, Z 8 [2 x 1/2 x Co(mbt)2(py)2],pobs 1.495, pcalc 1.495 g cm-3: Ni(mbt)2(py)2 is isostructural. The structure was obtained from 1847 observed diffractometer data (Cu Kα, θmax 55�), and refined to R 0.035, Rw 0.031.

Myocarditis masquerading as ischemic heart disease: the diagnostic utility of antimyosin imaging

The diagnosis of myocarditis presents a diagnostic challenge due to its varied clinical presentation. In addition, criteria for myocarditis are varied. At present, the confirmation of myocarditis depends on an endomyocardial biopsy demonstrating myocardial inflammation and necrosis. Unfortunately, this invasive procedure is associated with some degree of risk and has significant limitations. This report discusses the case presentations of two patients with chest pain, electrocardiographic changes and elevated creatine kinase levels suggestive of myocardial infarction, who were subsequently found to have findings compatible with myocarditis based on indium-111 antimyosin antibody scanning. This noninvasive test therefore appears to have value in the differentiation of myocardial ischemia from myocarditis.

A14 TRANSABDOMINAL BOWEL ULTRASOUND AND CLINICAL OUTCOMES OVER ONE YEAR IN CHILDREN WITH NEWLY DIAGNOSED CROHN’S DISEASE

Background

Transabdominal bowel ultrasound (TABUS) is an emerging non-invasive tool for monitoring inflammatory bowel disease (IBD). Its use is particularly increasing in pediatric IBD, given the need for anesthesia during endoscopy. The assessment of TABUS in pediatric IBD has been limited to small numbers of patients with no long-term follow-up.

Purpose

To describe TABUS findings and its relationship with clinical, biochemical, and endoscopic assessments in pediatric patients with Crohn’s disease up to one year post-diagnosis.

Method

Patients (0-18 years) with suspected IBD were prospectively enrolled through the Edmonton Pediatric IBD Clinic. Those with Crohn’s disease were included. Patients underwent repeated TABUS, clinical assessments, blood work, fecal calprotectin (FCP) (baseline, 1-, 3-, 6-, 12-months), and endoscopy (baseline and 6-12 months). The weighted Pediatric Crohn’s Disease Activity Index (wPCDAI), Simple Endoscopic Score for Crohn’s Disease (SES-CD; rectum excluded), and Simple Ultrasound Activity Score for Crohn’s Disease (SUS-CD; rectum excluded) were used. Remission was defined as FCP&lt;250mg/kg, CRP&lt;4mg/L, wPCDAI&lt;12, no upcoming surgery, and SES-CD score ≤2 for any bowel segment.

Result(s)

Fifty-six patients (68% male), median age 12.5 years (range 6-17), were followed for 6 months. Forty (71%) were followed up to 12 months. Median TABUS bowel wall thickness (BWT) and SUS-CD total scores improved in all bowel segments over time. SUS-CD total scores significantly correlated with SES-CD (baseline, 6-, 12-months), wPCDAI (baseline, 1-, 6-, 12-months), CRP (baseline, 1-, 3-, 6-months), ESR (baseline, 1-, 3-, 6-, 12-months), and FCP (baseline, 1-, 6-, 12-months) (rho ranged 0.302-0.732, p&lt;0.05). Patients in remission had sustained significantly thinner BWT of their most affected bowel segment (Figure 1) starting at 1-month (median 3.1mm (IQR 2.7-3.7) vs. 4.1mm (IQR 2.9-5.6; p&lt;0.05), and sustained significantly lower SUS-CD total scores starting at 6 months (median 0 (IQR 0-1) vs. median 2 (IQR 1-3); p&lt;0.05). Seven patients had surgery (n=7/7 ileocecal, n=2/7 jejunal resection). All 7 patients had complex TI disease (n=6 strictures, n=1 long-segment disease &gt;25cm) and proximal small bowel disease (n=2/2) on TABUS. Those with baseline ultrasound findings of a stricture with upstream bowel dilatation (n=7/56) had increased odds (OR=288, p&lt;0.01) and relative risk (RR=42, p&lt;0.01) of needing surgery (n=6/7 with baseline obstructive findings, n=1/49 without) within the first year.

Image

Conclusion(s)

TABUS had significant correlations with clinical, biochemical, and endoscopic markers of Crohn’s disease activity in pediatric patients over one year. Bowel wall thickness of the most affected bowel segment is a helpful measurement, becoming significantly thinner as soon as 1-month post-diagnosis in those who obtain remission. Baseline findings of bowel narrowing and upstream dilation increase the odds and relative risk of needing surgery in the first year.

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Disclosure of Interest

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Integrating general practice and hospital services

OBJECTIVES

To evaluate a model of negotiations between six Divisions of General Practice and four teaching hospitals, aimed at creating formal agreements to improve the GP-hospital interface.

METHOD

The evaluation examined the model's outcomes and participants' experiences. Outcomes were investigated via unstructured interviews with key informants, and analysis of relevant documentation. Participants' experiences were elicited via structured interviews with 11 Divisional members and 14 hospital representatives.

RESULTS

Progress towards agreements was made in all cases, with a full agreement being reached at one hospital. Negotiations are continuing in the remaining hospitals. Additional outcomes were achieved during the process, and included resources and structural arrangements involving GPs. Participants were satisfied with the model, but certain key issues were identified.

CONCLUSION

This evaluation suggests that for negotiations between GPs and hospitals to be successful, Divisions must be involved and be representative, hospitals must see value in formal agreements, their structure must be considered and the process must be collaborative. In the current policy context, which emphasises primary care, hospitals and GPs are increasingly likely to start working more cooperatively. This model has significant potential to improve the interface between the two parties, through its formal negotiation process, and could easily be adapted to other settings.