Initial experience with a novel pulsed field ablation catheter for ablation of atrial fibrillation: procedural findings and acute safety

Funding Acknowledgements

Type of funding sources: None.

Background

Currently employed catheters for treatment of symptomatic atrial fibrillation (AF) leverage thermal energy to ablate the myocardium. Despite excellent acute success rates, the non-selective nature of thermal injury has been associated with frequent AF recurrences and complications such as pulmonary vein stenosis and thermal damage to adjacent structures. Recently, a novel, non-thermal ablative modality has been introduced for the treatment of AF: pulsed field ablation (PFA). The selective nature of PFA translates in the ability to perform full transmural lesions whilst sparing adjacent tissues and structures, making PFA an attractive solution to limitations faced with thermal energy sources. Although several pre-clinical studies investigated the safety and feasibility of PFA, limited reports have been published so far describing the clinical application of this novel catheter technology.

Purpose

In this study we present our initial experience with a pulsed field ablation catheter and describe procedural findings and acute safety of the first 68 patients treated at our center.

Methods

We investigated the first 68 patients treated for symptomatic AF at our center using pulsed field ablation between July 2021 and January 2022. Procedural findings at the time of ablation are presented. Procedure-related complications are reported. Qualitative analysis of electrograms and electrophysiological maps before and after ablation are also provided. Lastly, learning curves of operators who performed more than 10 procedures are described.

Results

Mean age of patients was 63.1±9.2 years, and most were men (57.4%). Most patients suffered from paroxysmal AF (79.4%). The median CHA2DS2-VASc score was 2.0 (1.0; 3.0) and mean left-atrium (LA) volume index was 33.0±8.3 ml/m2. All procedures were performed using conscious sedation. In 63/68 patients ablation of the PVI was performed and in 5/68 patients additional ablation of the left atrial posterior wall was performed. 3D electroanatomic mapping was performed during 10/68 procedures which lasted on average 107.3±15.5 min. Procedures where no mapping was performed lasted on average 48.5±20.7 min. Mean LA time was 39.9±19.0 min. Mean number of applications per pulmonary vein (PV) were 8.6±1.1. In all patients (100%) PVs were confirmed to be isolated. Four different operators performed the ablations: operator 1 performed 25/58 procedures (36.8%), operator 2 28/58 (41.2%), operator 3 9/58 (13.2%), and operator 4 6/58 (8.8%). The learning curves of both operator 1 and operator 2 showed negligible variation of performance over time (R2: Operator 1 = 0.181; Operator 2 = 0.078). The only complications reported were two cases of bleeding at the percutaneous access site of the femoral vein.

Conclusions

Our initial experience with a PFA catheter in 68 patients shows that PFA is a safe, quick, easy-to-learn, and effective ablation technique for the treatment of symptomatic AF.

Heart rate increase and inappropriate sinus tachycardia after cryoballoon pulmonary vein isolation for atrial fibrillation

BACKGROUND

Cryoballoon pulmonary vein isolation (PVI) is a common therapy for atrial fibrillation (AF). While moderately increased sinus rhythm heart rate (HR) after PVI has been observed, inappropriate sinus tachycardia (IST) is a rare phenomenon. We aimed to investigate the prevalence and natural history of an abnormal sinus HR response after cryoballoon PVI.

METHODS

We included 169/646 (26.2%) patients with AF undergoing PVI with available Holter recordings before and 3, 6 and 12 months after the procedure. Patients with AF on Holter monitoring were excluded. Mean HR increase ≥ 20 bpm or an IST-like pattern (mean HR > 90 bpm or > 80 bpm when beta-blocking agents were used) following PVI was categorised as abnormal sinus HR response.

RESULTS

Following PVI, mean HR ± standard deviation increased in the entire group from 63.5 ± 8.4 to 69.1 ± 9.9 bpm at 3 months (p < 0.001), and to 71.9 ± 9.4 bpm at 6 months (p < 0.001). At 12 months, mean HR was 71.2 ± 10.1 bpm (p < 0.001). Only 7/169 patients (4.1%) met criteria for abnormal sinus HR response: mean HR was 61.9 ± 10.6 bpm (pre-ablation), 84.6 ± 9.8 bpm (3 months), 80.1 ± 6.5 bpm (6 months) and 76.3 ± 10.1 bpm (12 months). Even at 12 months, mean HR was significantly different from that pre-ablation in this group (p = 0.033). However, in patients meeting IST-like pattern criteria, mean HR at 12 months was no longer significantly different from that pre-ablation.

CONCLUSION

Few patients had an abnormal sinus HR response after PVI. Peak HR was observed 3 months after PVI, but HR was still significantly increased 12 months post-ablation compared with pre-ablation. An IST-like pattern was rarely observed. In these patients, HR decreased to pre-ablation values within a year.

HLA Correlations with Clinical Phenotypes and Risk of Metabolic Comorbidities in Singapore Chinese Psoriasis Patients

INTRODUCTION

Psoriasis is a systemic, chronic inflammatory disease that not only afflicts the skin but is also associated with cardiovascular disease and metabolic syndrome. The strongest susceptibility loci for the disease is within the human leukocyte antigen (HLA) complex, though specific HLA allelic associations vary between populations.

OBJECTIVE

Our objective was to investigate HLA associations with clinical phenotypes of psoriasis and metabolic syndrome in Chinese psoriasis cases.

METHODS

We conducted an observational case-control study in Singapore with a cohort of psoriasis cases consecutively recruited from an outpatient specialist dermatological center (n = 120) compared with 130 healthy controls.

RESULTS

Significant HLA associations with psoriasis were observed with HLA-A*02:07, B*46:01, C*01:02, and C*06:02. The three-locus haplotype of A*02:07-C*01:02-B*46:01 was also significant (odds ratio [OR] 3.07; p = 9.47 × 10^-5). We also observed an association between nail psoriasis and HLA-A*02:07 carriers (OR 4.50; p = 0.002), whereas C*06:02 carriers were less prone to have nail involvement (OR 0.16; p = 0.004). HLA-A*02:07 was also identified as a possible risk allele for hypertension (OR 2.90; p < 0.05), and C*01:02 was a possible risk allele for dyslipidemia (OR 3.36; p < 0.05), both known to be common comorbidities in patients with psoriasis.

CONCLUSION

Our results demonstrate the growing importance of discerning population-specific clinical phenotypes and their association with certain HLA alleles in psoriasis.

Use of dorsal buttress plate fixation for ulnar carpometacarpal joint fracture dislocations for early mobilization: outcomes of 11 cases

AIM

This study reviews the surgical outcomes of using dorsal buttress plate for open reduction and internal fixation of ulnar (5th, or 4th and 5th) CMCJ fracture subluxation or dislocations.

METHODS

A retrospective review of 11 patients at our center who underwent operative fixation with dorsal buttress plating technique was performed. The surgery was performed between February 2012 and March 2017. Outcome measurements include radiographic evaluation of time to union, grip strength, and range of motion of the wrist.

RESULTS

Of 11 patients in our case series, eight had injuries involving both 4th and 5th CMCJs, while three had isolated involvement of 5th CMCJ. Mean time to union on radiographs was 48 days (IQR 17.0; range 30-88). The median palmar flexion and dorsiflexion of the wrist were 56° (IQR 11.3; range 50°-80°) and 65° (IQR 10.0; range 60°-80°) respectively. Patients regained a median of 79% of grip strength (IQR: 36.0, range 43-100). All fingers achieved full range of motion, and no patient had scissoring of the fingers. Two patients had temporary mild numbness over the dorsoulnar aspect of the hand in the region of the 4th webspace. Five patients underwent removal of implants due to plate breakage (n = 2), or mild pain or pain with cold (n = 3). All patients were well after plate removal, and all the patients with pain had resolution of pain after implant removal.

CONCLUSION

The dorsal buttress plate is a viable option for fixation of ulnar CMCJ fracture dislocations to allow early mobilization.

Effect of interfragmentary gap on compression force in a headless compression screw used for scaphoid fixation

We investigated the effect of an interfragmentary gap on the final compression force using the Acutrak 2 Mini headless compression screw (length 26 mm) (Acumed, Hillsboro, OR, USA). Two blocks of solid rigid polyurethane foam in a custom jig were separated by spacers of varying thickness (1.0, 1.5, 2.0 and 2.5 mm) to simulate an interfragmentary gap. The spacers were removed before full insertion of the screw and the compression force was measured when the screw was buried 2 mm below the surface of the upper block. Gaps of 1.5 mm and 2.0 mm resulted in significantly decreased compression forces, whereas there was no significant decrease in compression force with a gap of 1 mm. An interfragmentary gap of 2.5 mm did not result in any contact between blocks. We conclude that an increased interfragmentary gap leads to decreased compression force with this screw, which may have implications on fracture healing.

AP1S3 Mutations Cause Skin Autoinflammation by Disrupting Keratinocyte Autophagy and Up-Regulating IL-36 Production

Prominent skin involvement is a defining characteristic of autoinflammatory disorders caused by abnormal IL-1 signaling. However, the pathways and cell types that drive cutaneous autoinflammatory features remain poorly understood. We sought to address this issue by investigating the pathogenesis of pustular psoriasis, a model of autoinflammatory disorders with predominant cutaneous manifestations. We specifically characterized the impact of mutations affecting AP1S3, a disease gene previously identified by our group and validated here in a newly ascertained patient resource. We first showed that AP1S3 expression is distinctively elevated in keratinocytes. Because AP1S3 encodes a protein implicated in autophagosome formation, we next investigated the effects of gene silencing on this pathway. We found that AP1S3 knockout disrupts keratinocyte autophagy, causing abnormal accumulation of p62, an adaptor protein mediating NF-κB activation. We showed that as a consequence, AP1S3-deficient cells up-regulate IL-1 signaling and overexpress IL-36α, a cytokine that is emerging as an important mediator of skin inflammation. These abnormal immune profiles were recapitulated by pharmacological inhibition of autophagy and verified in patient keratinocytes, where they were reversed by IL-36 blockade. These findings show that keratinocytes play a key role in skin autoinflammation and identify autophagy modulation of IL-36 signaling as a therapeutic target.

Inborn Error of Metabolism (IEM) screening in Singapore by electrospray ionization-tandem mass spectrometry (ESI/MS/MS): An 8 year journey from pilot to current program

IEM screening by ESI/MS/MS was introduced in Singapore in 2006. There were two phases; a pilot study followed by implementation of the current program. The pilot study was over a 4 year period. During the pilot study, a total of 61,313 newborns were screened, and 20 cases of IEM were diagnosed (detection rate of 1:3065; positive predictive value (PPV) of 11%). Regular self-review, participation in external quality assessment and the Region 4 Genetic collaborative programs (http://www.region4genetics.org/) had led to the robust development of our current NBS MS/MS program. Overall, from July 2006 to April 2014, we screened a total of 177,267 newborns. The mean age at the time of sampling was 47.9h. Transportation of samples to the testing laboratory averaged 0.92 day. Upon receipt of sample, the NBS result was available within 1.64 days and within 3.8 days if a second tier test was required. Using absolute cut-off values in place of the initial 99th percentile reference range for the analyte markers and the introduction of two 2nd tier tests (MMA and Succinylacetone) had significantly reduced the high recall rate from an initial 1.5% during the period 2006-07 to 0.12% in 2013. The NBS MS/MS program was supported by a centralized confirmatory/diagnostic testing laboratory and a rapid response team of metabolic specialists. The detection rate was 1: 3165 (1:2727 if maternal conditions were also included). There were 23 newborns affected with organic acidemias (incidence: 1:6565), 23 with fatty acid oxidation disorders (incidence: 1:6565), and 10 with amino acidopathies (incidence 1:17,726). The performance metrics for the screening test were acceptable (sensitivity: 95.59%, specificity: 99.85%, PPV: 20%, FPR: 0.15). Participation in the NBS MS/MS program by hospitals was voluntary, and in 2013, the uptake rate was 71% of the annual births. We hope that newborn screening by MS/MS will become a standard of care for all babies in Singapore.

Non-ketotic hyperglycinemia is usually not detectable by tandem mass spectrometry newborn screening

Diagnosis of Non-Ketotic Hyperglycinemia by MSMS newborn screening might benefit patients with post-neonatal presentation. We screened 733,527 babies over eight years, and nine babies were subsequently diagnosed with NKHG. Two had newborn glycine levels above our cut-off and presented within 72 h. The remaining patients could not have been diagnosed by newborn screening without an unacceptably high recall rate. We conclude that babies with NKHG are not usually identifiable by current newborn screening strategies.

Myocardial viability assessment: poor correlation between electromechanical cardiac mapping and positron emission tomography in severe coronary artery disease

BACKGROUND

An intracardial electromechanical mapping system has recently been introduced which offers the ability to perform on-line myocardial viability assessment in the catheterisation laboratory. Only a small number of studies have been performed to validate this potentially very useful technique.

AIM

We sought to assess the correlation between viability assessment performed with both positron emission tomography (PET) and electromechanical cardiac mapping (EMM) in patients suffering from severe coronary artery disease, since PET is considered the golden standard in myocardial viability assessment.

METHODS

Patients undergoing both EMM and PET analysis were systematically scanned for viability assessment. EMM analysis was performed for both linear local shortening and unipolar voltage. PET analysis consisted of dipyridamole stress and fluoro-deoxy-d-glucose (FDG) measurements. All data were converted to nine-segment bull's-eye maps to allow comparison. One single operator analysed all the data, blinded for clinical status.

RESULTS

34 patients suffering from severe coronary artery disease underwent both PET and EMM analysis. In total 253 EMM segments had more than four contact points and could be used for analysis. Unipolar voltage showed a trend towards lower values in infarcted segments; however, linear local shortening did not show any correlation.

CONCLUSION

In this study viability assessment by EMM did not correspond with PET analysis. Although the advantage of having some form of online myocardial assessment is evident, operators should bare in mind that the quantitative EMM measurements are not an absolute substitute for nuclear imaging.

Reduction of endothelial dysfunction following VEGF gene therapy

BACKGROUND/OBJECTIVES

Vascular endothelial growth factor (VEGF) is a potent angiogenic factor. VEGF gene therapy improves perfusion of ischaemic myocardium in experimental models and possibly in patients with end-stage coronary artery disease. In addition to its proliferative and migratory effect on endothelial cells, it also activates and upregulates eNOS. Therefore, we investigated coronary endothelium-dependent vasodilatation in patients before and after VEGF gene therapy.

METHODS

The effect of intracoronary acetylcholine infusion on coronary diameter was assessed at baseline and after three months of follow-up in patients with end-stage coronary artery disease treated with VEGF gene and in controls scheduled for elective PTCA (acetylcholine test at diagnostic angiography and before a subsequently scheduled PTCA).

RESULTS

Eight out of ten VEGF patients experienced a reduction in anginal symptoms. Angiographic evidence for improved collateral filling was evident in two out of six patients. The vasoconstrictive response to acetylcholine was partly converted into dilatation. In contrast, the acetylcholine response in control patients remained vasoconstrictive.

CONCLUSION

VEGF gene therapy has an important beneficial effect on the functional characteristics of the myocardial vascular network. Therefore, this therapy can potentially play an important role in all stages of the atherosclerotic process.

SMN1 deletions among singaporean patients with spinal muscular atrophy

INTRODUCTION

Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disorder characterised by degeneration of spinal cord anterior horn cells, leading to muscular atrophy. It is the second most frequent autosomal recessive disease among Caucasian populations with a prevalence of between 1 in 6000 and 1 in 10,000 live births, and a carrier frequency of about 1 in 50. The International SMA Consortium classification defines several types of SMA depending on the age of onset and clinical severity. In the past, the diagnosis of SMA was confirmed by muscle biopsy and, sometimes, electromyography. In 1990, SMA was linked to the 5q13 region of chromosome 5. In 1995, it was found that >95% of patients with SMA have homozygous deletions of exons 7 and 8 of the survival motor neurone 1 (SMN1) gene, one of the candidate genes identified within 5q13. The purpose of our study was to determine the frequency of SMN1 deletions in patients with known SMA and the impact of this on the diagnosis of SMA.

MATERIALS AND METHODS

Molecular analysis was performed on stored DNA and case notes were reviewed retrospectively.

RESULTS

Twenty-two (91.7%) out of 24 patients with all types of SMA were homozygously deleted for exons 7 and/or 8 of SMN1. We also report our experience with prenatal diagnosis of SMA.

CONCLUSIONS

Molecular studies can replace conventional investigations for SMA and have made the option of prenatal diagnosis possible for couples at risk.

Radiofrequency ablation of atrial fibrillation

Twenty-five patients (16 males, mean age 46 years) underwent radiofrequency ablation because of either paroxysmal (13 patients) or persistent atrial fibrillation (12 patients). Ablation aimed at earliest activation of spontaneous and catheter-induced repetitive ectopy in left and right atria and appendages, and pulmonary veins. Catheter-induced repetitive ectopy was defined as acute onset of a burst of rapid atrial premature beats on touching the wall, sustained irritability while at the spot and acute termination of rapid activity upon release of the catheter. Post-ablation patients received antiarrhythmic drugs to prevent tachycardias, thereby allowing reversal of atrial remodeling.

RESULTS

Lone atrial fibrillation was present in 19 patients, 4 patients had hypertension and 2 patients coronary artery disease with preserved left ventricular function. The median duration of the history of atrial fibrillation was 4 years (range 1-14 years) and the median number of antiarrhythmic drug failures 5 (range 1-6). Ablation was successful, i.e. no recurrences of atrial fibrillation with or without antiarrhythmic drugs in eight patients (32%) during a median follow-up of 28 months (range 18-52). The median number of foci was 3 (range 2-6) and 2 (range 1-7) in the successfully and unsuccessfully treated patients, respectively. Minor complications occurred in three patients.

CONCLUSIONS

Radiofrequency ablation of atrial fibrillation aiming at spontaneous and catheter-induced repetitive ectopy is a safe procedure. However, it is only successful in one third of the patients. Further investigations are warranted to identify the ideal patient, as well as to develop better ablation strategies.

Safety evaluation of routine intracoronary acetylcholine infusion in patients undergoing a first diagnostic coronary angiogram

BACKGROUND

Recent findings imply prognostic significance of intracoronary acetylcholine infusion for endothelial function testing. We evaluated whether routine use of this test in coronary angiography patients is safe.

METHODS

Patients undergoing a first diagnostic coronary angiography were selected to receive intracoronary acetylcholine for endothelial function evaluation. The relation between adverse reactions during infusion and risk factors was analyzed with a logistic regression model. Included in the multiple logistic regression model were the variables with a univariate P value < 0.20.

RESULTS

Adverse reactions occurred in 16% (49/299) of the patients. This included two life-threatening events caused by occlusive spasm and flow limitation in the left coronary artery. Other adverse events were chest pain (n = 38), AV block or sinus bradycardia (n = 10), dyspnea (n = 3). Adverse reactions were more likely to occur in patients younger than 60 years of age (relative risk, 5.6 [2.2-14.3]).

CONCLUSION

Intracoronary acetylcholine infusion is safe, but may lead to serious adverse reactions. Care should be taken especially in patients younger than 60 years of age. Routine use of acetylcholine infusion can thus only be justified if it has important prognostic significance. This has to be proven further in large prospective studies.

Mental health in Asia: social improvements and challenges

Remarkable improvements in economic conditions and a considerable upgrade in the quality of life have been observed in many parts of Asia during the past several decades. At the same time, many mental health challenges face the people of Asia. Various social mental health indexes are reviewed here, with available data from China, Japan, Korea, Singapore, Malaysia, and other Asian societies. The data are compared with data from the United States, Australia in the Pacific Rim, and some other Western countries to examine patterns of similarity or difference between East and West in the process of modernization. Common trends in mental health issues associated with rapid sociocultural change observed in different Asian societies are discussed, as well as the relative shortage of mental health personnel available in many Asian societies. It is emphasized that, in addition to expanding psychiatric services, there is an even more urgent need to promote mental health knowledge and concern through education in the general population. Mental health needs to be cultivated and maintained by social forces and cultural strengths. It is stressed that there is a challenge for Asian people to advance mental health beyond economic development in the 21st century.

Durability of aortic valve preservation and root reconstruction in acute type A aortic dissection

BACKGROUND

The aim of this study was to determine the durability of aortic valve preservation and root reconstruction in type A aortic dissection with involvement of the aortic root.

METHODS

From November 1976 to February 1999, 246 patients underwent surgical treatment for acute type A aortic dissection at our institution. In 121 patients (49%), all with acute type A dissection and aortic root involvement, the aortic valve was preserved and one or more of the sinuses of Valsalva were reconstructed. The mean age of this group was 59 +/- 11 years and 70 (58%) were men. Thirty patients (25%) were operated in cardiogenic shock. Criteria for aortic root reconstruction were technical feasibility and surgeon preference. Techniques used for reconstruction were valve resuspension in all patients and additional reinforcement of the aortic root with Teflon (L.R. Bard, Tempe, AZ) felt (n = 21), gelatin-resorcinol-formaldehyde-glue (GRF-glue, Fii, Saint-Just-Malmont, France) (n = 103), or fibrinous glue (Tissu-col, Immuno AG, Vienna, Austria) (n = 5). Mean follow-up was 43.5 +/- 46 months.

RESULTS

The operative mortality was 21.5% (n = 26). Actuarial survival was 72% +/- 4%, 64% +/- 5%, and 53% +/- 6% at 1, 5, and 10 years, respectively. Median aortic regurgitation in patients with retained native aortic valve at follow-up was 1+. All root reoperations included aortic valve replacement (n = 12). Freedom from aortic root reoperation was 95% +/- 2% at 1 year, 89% +/- 4% at 5 years, and 69% +/- 9% at 10 years. The incidence of aortic root reoperation was 23%, 11%, and 40%, respectively, when Teflon felt, GRF-glue, and fibrinous glue were used for root reconstruction. Multivariate Cox proportional hazard analysis revealed the use of fibrinous glue (RR = 8.7; p = 0.03) as well as the presence of an aortic valve annulus more than 27 mm (RR = 4.2; p = 0.04) as independent risk factors for aortic root reoperation.

CONCLUSIONS

Aortic valve preservation in acute type A dissection provides relatively durable results. The use of fibrinous glue for root reconstruction seems to compromise the long-term durability of the repair compared with Teflon felt and GRF-glue. A dilated aortic annulus requires a more extensive root procedure.

Worse clinical outcome but similar graft patency in women versus men one year after coronary artery bypass graft surgery owing to an excess of exposed risk factors in women. CABADAS. Research Group of the Interuniversity Cardiology Institute of The Netherlands. Coronary Artery Bypass graft occlusion by Aspirin, Dipyridamole and Acenocoumarol/phenoprocoumon Study

OBJECTIVES

This retrospective study sought to assess differences in graft patency and clinical outcome between women and men after coronary artery bypass graft surgery (CABG).

BACKGROUND

A less favorable clinical outcome has been reported in women as compared with men. Its relation to graft patency has not been studied.

METHODS

We analyzed one-year follow-up data of 912 patients (120 women) who entered a randomized clinical drug trial. All patients received vein grafts; in 494 patients (56 women) internal mammary artery (IMA) grafts were also used. Graft patency was assessed by coronary angiography at one year. Primary clinical end points were myocardial infarction, revascularization procedures and death; secondary clinical end points included recurrent angina, heart failure and arrhythmias.

RESULTS

Occlusion rates of vein grafts were 16.7% in women and 12.4% in men (odds ratio [OR] 1.62, 95% confidence interval [CI] 0.88 to 3.00, p = 0.12); occlusion rates of IMA grafts were 3.4% and 5.7% in women and men, respectively (OR 0.56, 95% CI 0.08 to 3.96, p = 0.56). Primary clinical end points were observed in 16.7% of women and 9.2% of men (OR 1.97, 95% CI 1.10 to 3.34, p = 0.022), and any clinical end point in 41.7% of women and 25.8% of men (OR 2.06, 95% CI 1.39 to 3.04, p = 0.0004). Myocardial infarction (15% vs. 7.6%, OR 2.15, 95% CI 1.24 to 3.75, p = 0.013) and recurrent angina (26.7% vs. 15.4%, OR 2.00, 95% CI 1.28 to 3.11, p = 0.004) occurred most frequently. Multivariate regression analysis did not identify gender as an independent risk factor for graft occlusion or the clinical end points. Graft occlusion was an independent predictor of the composite primary clinical end point (OR 2.75, 95% CI 1.59 to 4.75, p = 0.0003) and each of the secondary clinical end points. The observed differences were due to an imbalance of risk factors at baseline and to surgical and graft characteristics.

CONCLUSIONS

One-year occlusion rates of vein and IMA grafts were comparable in women and men. Clinical outcome was related to graft patency and was less favorable in women owing to their uneven distribution of risk factors among both groups.

Aspirin therapy in nonarteritic anterior ischemic optic neuropathy

PURPOSE

To determine the benefit of aspirin in reducing the risk of nonarteritic anterior ischemic optic neuropathy in the fellow eye following its occurrence in the first eye.

METHODS

A retrospective cohort study was conducted on 431 patients, 153 of whom were and 278 of whom were not prescribed aspirin following the development of unilateral nonarteritic anterior ischemic optic neuropathy.

RESULTS

The 2-year cumulative probability of nonarteritic anterior ischemic optic neuropathy in the fellow eye was 7% in the aspirin group and 15% in the no-aspirin group, and 5-year cumulative probabilities were 17% and 20%, respectively. Compared with the no-aspirin group, the rate ratio for nonarteritic anterior ischemic optic neuropathy in the fellow eye in the aspirin-user group was 0.43 (95% confidence interval, 0.19 to 0.92) over the first 2 years and 0.68 (95% confidence interval, 0.36 to 1.26) over the 5-year period. The overall calculated 5-year risk was 19%; however, if none of the patients with incomplete follow-up developed nonarteritic anterior ischemic optic neuropathy in the fellow eye, then the 5-year risk would be about 12%.

CONCLUSIONS

The 5-year risk of nonarteritic anterior ischemic optic neuropathy occurring in the second eye is far lower than that reported by previous studies. Our results suggest a possible short-term but little or no long-term benefit to aspirin in reducing the risk of nonarteritic anterior ischemic optic neuropathy in the fellow eye. However, this finding must be viewed with caution because this study was not conducted prospectively with a controlled protocol.

Comparison of myocardial uptake of fluorine-18-fluorodeoxyglucose imaged with PET and SPECT in dyssynergic myocardium

PET with 18F-fluorodeoxyglucose (FDG) can detect viable myocardium and predict functional recovery after revascularization. The use of PET for clinical routine, however, is limited. Recently, imaging FDG with SPECT was proposed. The aim of this study was to compare the diagnostic value of FDG-PET and FDG-SPECT in the detection of viable myocardium in segments with abnormal wall motion.

METHODS

Twenty patients with previous myocardial infarction were studied. All underwent FDG-PET and FDG-SPECT during hyperinsulinemic glucose clamping. Regional perfusion was assessed with 13N-ammonia PET and early resting 201TI- SPECT. Regional wall motion was assessed with two-dimensional echocardiography. The agreement between FDG/13N-ammonia PET and FDG/201TISPECT to detect viability in dyssynergic myocardium was 76%. On a patient basis, PET and SPECT yielded comparable results in 17 of 20 patients. In a subgroup of patients with LVEF < or = 35% (n = 12), all PET and SPECT viability data were identical.

CONCLUSION

This study shows a good correlation between the detection of viability in dyssynergic myocardium with FDG/13N-ammonia PET and FDG/201TI SPECT, both on a segmental and patient basis.

Comparison between positron emission tomography myocardial perfusion imaging and intracoronary Doppler flow velocity measurements at rest and during cold pressor testing in angiographically normal coronary arteries in patients with one-vessel coronary artery disease

With use of invasive methods, coronary endothelial function is generally studied by examining the response of epicardial coronary arteries to intracoronary administered acetylcholine or to cold pressor testing. Because invasive methods have substantial inherent limitations, studies should attempt to evaluate coronary endothelial function noninvasively. This study examines a noninvasive technique for endothelium-related coronary stress testing. In myocardial regions supplied by nonstenotic coronary arteries, we compared positron emission tomography (PET) myocardial perfusion imaging with intracoronary Doppler flow velocity measurements during endothelium-related stress testing. PET perfusion was examined at rest and during cold pressor testing in 10 patients with 1-vessel coronary artery disease. In nonstenotic coronary arteries, flow velocity measurements were obtained at rest, during cold pressor testing, and during intracoronary administered acetylcholine. Perfusion and flow velocity responses and stress/rest ratios were compared between the techniques during the various circumstances. Positive correlations were found between: (1) cold pressor Doppler flow velocity responses and acetylcholine Doppler flow velocity responses (r = 0.84, SEE = 0.19, p = 0.003); (2) cold pressor PET perfusion responses and cold pressor Doppler flow velocity responses (r = 0.70, SEE = 0.17, p = 0.02); and (3) cold pressor PET perfusion responses and acetylcholine Doppler flow velocity responses (r = 0.62, SEE = 0.19, p = 0.05). These results suggest that in angiographically normal coronary arteries, both the flow velocity and the perfusion responses during cold pressor testing may be related to the response to acetylcholine.

The neurogenic bladder in spinal cord injury--pattern and management

This study describes the various types of neurogenic bladder in spinal cord injury in relation to the level of lesion, defines the aims of bladder management, and discusses the importance of highly individualised management strategies and long-term follow-up. Urodynamic studies were done on 47 new patients with traumatic spinal cord injury when they had return of reflexic bladder activity. This study was conducted over a one-year period. Fifty-five per cent (n = 26) sustained cervical injuries (38.5% complete, 61.5% incomplete), 12.8% (n = 6) had thoracic injuries, 29.8% (n = 14) had lumbar injuries, and 2.1% (n = 1) had sacral injury. The urodynamic patterns according to injury level are shown in Table I. In patients with complete cervical injuries, 80% had detrusor sphincter dyssynergia (DSD), and areflexia was seen in 20% (n = 2). Of those with incomplete cervical injury, 7 (43.8%) had DSD, 5 (31.3%) had detrusor hyperrflexia without DSD, and 2 (12.5%) had areflexia or hyporeflexia. Normal urodynamic studies were only found in patients with incomplete cervical injury (n = 2). Of the 6 patients with thoracic injury, 4 (66.6%) had detrusor areflexia and 2 had DSD. The 2 patients with DSD had injury levels at T4/T6 and T5 respectively. Eleven (78.6%) patients with lumbar injury had detrusor areflexia, one (7.1%) had detrusor hyperreflexia (without DSD), and 2 (14.3%) had a normal urodynamic study. The various patterns of bladder management are shown in Table II. In total, there were 17 patients with DSD. Of these, 9 (52.9%) elected for intermittent catheterisation together with pharmacological therapy, 5 (29.4%) passed urine via spontaneous voiding/tapping, one (5.9%) had an in-dwelling catheter by virtue of his lack of manual dexterity and no care-giver, and 2 (11.8%) patients opted for sacral anterior root stimulator (SARS) or the Brindley device. Of the 6 patients with detrusor hyperreflexia, 4 (66.7%) passed urine spontaneously and 2 (33.3%) patients choose intermittent catheterisation together with pharmacologic therapy. There were 20 patients with detrusor areflexia/hyporeflexia; 15 (75%) were on clean intermittent catheterisation, 4 (20%) voided via straining and 1 (5%) had a suprapubic catheter inserted. The re-discovery of intermittent self-catheterisation, improved medical care, bladder training and surgical advances have enabled the goals of bladder management to be realised; namely safe bladder pressures, low residual urine volume and the attainment of continence.

Microchip implants on the anterior sacral roots in patients with spinal trauma: does it improve bowel function?

PURPOSE

This study evaluated the effect of anterior sacral roots stimulator implants on bowel function of patients with spinal cord trauma.

METHOD

Eight patients with spinal cord injury and constipation had anterior sacral roots stimulator implants inserted for concomitant bladder dysfunction. Questionnaires on bowel function and anorectal manometry tests were given before and after insertion of the implants.

RESULTS

Six patients achieved improvement in bowel function. Four of these patients could defecate spontaneously following stimulation. Two patients had no improvement in bowel function. Anorectal manometry studies showed a negative rectoanal pressure difference at the time of stimulation. All patients were unable to defecate during stimulation. Positive rectoanal pressure difference was recorded in the six patients who had improved bowel function. This may be attributable to the slower relaxation of the smooth rectal muscle compared with the easily fatigable striated external anal sphincter.

CONCLUSION

Anterior sacral roots stimulator implants can improve bowel function in patients with spinal cord trauma.

Paroxysmal hypertension in a C4 spinal cord injury--a case report

Hypertension in a patient with acute spinal cord injury is commonly caused by autonomic dysreflexia, which is a syndrome of paroxysmal hypertension associated with headaches, relative bradycardia and vasomotor instability secondary to sympathetic overactivity. Life-threatening complications such as seizures and intracerebral haemorrhage are largely preventable. We report both acute and chronic forms of autonomic dysreflexia due to underlying urinary and faecal impaction in a 33-year-old female with traumatic C4 quadriplegia. She was successfully managed with a combination of physical and pharmacological measures including calcium channel and sympathetic blockers.

Exercise systolic arterial blood pressure in middle-aged women with normal and elevated arterial blood pressure

Considerable interindividual variation in the response of blood pressure to exercise has been found. Factors independently contributing to this variation are insufficiently evaluated. This is especially true for women and older age groups. Reference values of progressive maximal exercise testing in middle-aged, active subjects, especially in women, are scarce. In this study, the response of systolic arterial blood pressure during a progressive maximal cycle ergometer test was investigated in 871 physically active female subjects aged 40 years or older with normal, borderline elevated and elevated blood pressure. The influence of 14 different subject characteristics on this response was studied: 63% of variation in exercise systolic blood pressure (eSBP) could be explained by work load, pre-eSBP, age and exercise heart rate. No difference in eSBP with increasing work load was found between the three groups. Subjects with higher exercise heart rates had higher systolic blood pressures at the same work load compared to subjects with lower exercise heart rates. Maximal working capacity (Wmax) was significantly lower in the elevated blood pressure group although maximal heart rate and lactate were similar. Wmax was age-dependent. Other subject variables were not significantly associated with eSBP. Values of eSBP for reference purposes are presented.

Functional outcome in young strokes

Fifty-seven young stroke patients (aged 45 years and below) admitted to a rehabilitation centre were assessed for underlying risk factor/aetiology and functional outcome after rehabilitation. The mean age was 37.2 +/- 6.3 years and the mean length of stay in the rehabilitation ward 38.3 +/- 19.9 days. There were 37 (64.9%) haemorrhagic and 20 (35.1%) ischaemic strokes. Hypertension was the single most important risk factor accounting for 49.1% of all strokes. Vascular abnormalities (arteriovenous malformation, mycotic aneurysm, vasculitis and Moya-moya disease) and cardiogenic embolism secondary to rheumatic valvular heart disease were also significant causes. There was significant improvement in functional status--activities of daily living (ADL) and mobility--after rehabilitation, the mean Functional Status score improving from 9.76 +/- 2.2 on admission to 5.07 +/- 1.95 on discharge (P < 0.01). Higher ADL and mobility function and upper and lower limb motor power of grade 3 and above on admission, absence of dysphasia, left hemiplegia, age less than 40 years and rehabilitation stay of less than 28 days were associated with better functional outcome whilst sex, nature and site of stroke, and length of stay in the acute ward had no significant bearing.

Detrusor hyperreflexia in strokes

Urodynamic evaluation via water cystometry was undertaken in 27 patients from 12 to 120 days after cerebrovascular accidents. Seven patients had urinary symptoms--five with urge incontinence, one with frequency and one with sensation of incomplete bladder emptying. The remaining 20 were asymptomatic. Cystometry revealed normal bladder function in 15 patients (55.6%), detrusor areflexia in one patient (3.7%) and detrusor hyperreflexia in 11 patients (40.7%). Of the 11 patients with detrusor hyperreflexia, six (54.5%) were asymptomatic and the remaining five (45.5%) had urge incontinence. The former group had a statistically significant higher first sensation and functional cystometric capacity than the latter. Urge incontinence was also found to be an accurate predictor of detrusor hyperreflexia.

Reflex sympathetic dystrophy in hemiplegia--two case reports and review of the literature

Reflex sympathetic dystrophy (RSD) can be precipitated by a variety of events. We report two cases of RSD in hemiplegic patients detected within three months of the cerebrovascular accidents. Diagnosis of RSD was based upon clinical and scintigraphic findings. Management included elevation, range of movement of the affected joints and analgesics. With treatment, the pain and swelling subsided, range of motion of joints improved and the patients were able to participate in the rehabilitation programme. A high index of suspicion, early diagnosis and aggressive treatment were found to be essential for the successful treatment of RSD.

[Carbon monoxide poisoning as a trigger for myocardial infarction]

A male aged 70 became unwell during work on the motor of his boat. He had an acute myocardial infarction, complicated by arrhythmias, which had probably been triggered by carbon monoxide intoxication. After treatment with, among other things, oxygen he recovered. Although the patient had experienced mild angina pectoris in the past, he had been symptom-free for years without medication. It is therefore suggested that the carbon monoxide intoxication played an important part in this case.

Outcome of patients with cervical spondylotic myelopathy seen at a rehabilitation centre

A retrospective study was conducted on 21 patients with cervical spondylotic myelopathy to study the clinical characteristics of these patients and the influence of surgery and rehabilitation on their outcome. All the patients were 50 years and above, with a mean age of 63.6 years. The most common presenting feature was weakness of all the limbs. Neckache was not a prominent finding. Although only 2 patients complained of bladder disturbance, 6 other patients were found to have bladder dysfunction after urodynamic assessment. Clinical outcome after surgery was 50% improved, 28% unchanged and 22% worsened. Fifty percent of the patients with voiding problems recovered after bladder training. Rehabilitation was significant in assisting in the recovery of patients after surgery. One patient had a disabling stroke 4 days after cervical surgery while another died of urinary tract infection while undergoing rehabilitation.

Speech disorders in closed head injury patients

Head injuries vary in type and degree of severity and clinicians agree that most individuals who suffer head injury have cognitive, speech injury, behavioural and sensory motor problems immediately after and during their rehabilitative phase.

METHOD

The hospital courses of thirty-one closed head injury (CHI) patients admitted to our Rehabilitation Department from January 1990 to April 1991 were studied with particular reference to their speech disorders.

RESULTS

Severity of the initial brain injury, best measured by length of coma using the Glasgow Coma Scale (GCS) was the most significant predictor of outcome, defined by the Glasgow Outcome Scale (GOS). Eighty-one percent of our patients were unconscious immediately following their injury. Upon admission into our neurosurgical department, thirty-nine percent were comatose with a Glasgow Coma Scale score of eight or less. Fifty-two percent had a score of twelve or more and the rest were in between. Twenty-six percent had skull fractures, while seventy-four percent had one or more extracranial injuries. Neurologically eighty-one percent of our patients had either a left or right hemiplegia/paresis. In the assessment of speech, thirty percent were aphasic, twenty-five percent had motor speech disorders, thirty-two percent had mixed speech deficits and thirteen percent did not have any significant speech problems. Average stay in the Rehabilitation Department was ten weeks.

CONCLUSION

Although most patients showed an overall trend of speech improvement across time, the severely injured (Glasgow Coma Scale less than eight) continued to manifest permanent residual deficits especially those with expressive, mixed or global aphasia. The mild to moderately injured (Glasgow Coma Scale more than eight) seem to have anomia and word retrieval difficulty with little receptive language impairment, and these persisted months after discharge.

Bladder training in patients with spinal cord injury

Immediately following severe injury to the spinal cord or conus medullaris, there is a stage of flaccid paralysis of the bladder. The smooth muscle of the detrusor and rectum is affected. Drainage of the bladder is very important in the early care of such patients. From August 1989 to August 1990, 55 spinal cord injury patients were studied on admission to our department. The current bladder training method used for these patients is presented. A patient was deemed to have been successfully bladder trained when catheter-free, continent, and able to consistently maintain a residual volume of 100 mL or less with the aid of tapping and compression. On discharge 45 patients (82%) were successfully bladder trained, 8 (15%) employed a regimen of clean intermittent self-catheterization, and 2 went home/institutional care with an indwelling catheter. The material presented is applicable to any type of neurogenic bladder dysfunction.

Measuring quantity and frequency of drinking in a general population survey: a comparison of five indices

This article compares five indices of alcohol consumption in a general population survey conducted in 1985 in the Netherlands. Self-reports of consumption were obtained with a prospective diary, a retrospective 7-day recall method, and three summary measures, such as a quantity-frequency index. The coverage of sales data appeared highest for the diary (67%), which suggests a higher validity. Special attention was given to comparisons of quantity and frequency of drinking between the diary, on the one hand, and the weekly recall and summary measures, on the other. It was found that underreporting, relative to the diary reports, was generally higher in the frequency than in the quantity domain. This result, together with the finding from longitudinal studies that intraindividual variation is also higher for drinking frequency, leads to the conclusion that forgetting is a potent source of undercoverage in surveys and to the hypothesis that large differences in overall drinking pattern between populations (e.g., in regularity of drinking) may account for the large differences in coverage rates of sales data. Furthermore, the subjectively assessed probability of drinking by means of a "usual" frequency question appeared a poor predictor of (diary) drinking frequency for respondents reporting a low or moderate frequency. For subjects claiming a high "usual" drinking frequency, a reasonable correspondence between diary and summary measures was found. This mitigates the fear often expressed that heavy drinkers particularly underreport their consumption.

Urinary tract infection in acute spinal cord injury

Preservation of renal function and prevention of recurrent urinary tract infections is the ultimate goal of any method of neurogenic bladder management in spinal cord injury patients. METHOD--The hospital courses of fifty such patients admitted to our Rehabilitation Department from August 1989 to August 1990 were studied according to age, gender, spinal cord injury level, method of bladder drainage on admission and upon discharge, type of urinary tract infections and results of bladder management were documented. RESULTS--Forty-five men and ten women were studied. Mean age of males was forty and females, forty-two. The commonest cause of injury was road traffic accident followed by accidents at work place. Fifty-three percent had cervical cord injuries, thirteen percent thoracolumbar and sixteen percent lumbo sacral injuries. Seventy-eight percent had an indwelling foley catheter upon admission. Upon discharge eighty-two percent of spinal cord injury patients were able to void with/without tapping and compression. There were a total of one hundred and forty-three urinary tract infections in our study group. All positive urine cultures had greater than or equal to 100,000 CFU/ml. The commonest organisms causing urinary tract infection were Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Proteus mirabilis. CONCLUSION--For bacteria to produce disease in the urinary tract, they must gain access and colonise the uroepithelium, induce inflammation and tissue damage. The indwelling catheter provides a direct access to the uroepithelium, making bacteriuria and subsequent infection inevitable. Impaired voiding and sensation in spinal cord injury patients provides an excellent reservoir for the multiplication of bacteria, tissue invasion and recurrent urinary tract infection. Hence current methods of neurogenic bladder management have to focus on attaining a catheter-free status as soon as possible; relevant antibiotic therapy and careful attention to individual urinary tract problems to reduce morbidity and improve on spinal cord injury patient's future. Although spinal cord injury patients are described, the material covered is applicable to any type of neurogenic bladder dysfunction.

Recurrent cerebral thrombosis associated with protein S deficiency in a Chinese female

A 52-year-old Chinese female with recurrent cerebral thrombosis associated with hereditary protein S deficiency is described. The need to consider clotting disorders in young patients with no known risk factors for stroke is emphasized.

Endoscopic biliary drainage for severe acute cholangitis

BACKGROUND

Emergency surgery for patients with severe acute cholangitis due to choledocholithiasis is associated with substantial morbidity and mortality. Because recent results suggested that emergency endoscopic drainage could improve the outcome of such patients, we undertook a prospective study to determine the role of this procedure as initial treatment.

METHODS

During a 43-month period, 82 patients with severe acute cholangitis due to choledocholithiasis were randomly assigned to undergo surgical decompression of the biliary tract (41 patients) or endoscopic biliary drainage (41 patients), followed by definitive treatment. Hospital mortality was analyzed with respect to the use of endoscopic biliary drainage and other clinical and laboratory findings. Prognostic determinants were studied by linear discriminant analysis.

RESULTS

Complications related to biliary tract decompression and subsequent definitive treatment developed in 14 patients treated with endoscopic biliary drainage and 27 treated with surgery (34 vs. 66 percent, P greater than 0.05). The time required for normalization of temperature and stabilization of blood pressure was similar in the two groups, but more patients in the surgery group required ventilatory support. The hospital mortality rate was significantly lower for the patients who underwent endoscopy (4 deaths) than for those treated surgically (13 deaths) (10 vs. 32 percent, P less than 0.03). The presence of concomitant medical problems, a low platelet count, a high serum urea nitrogen concentration, and a low serum albumin concentration before biliary decompression were the other independent determinants of mortality in both groups.

CONCLUSIONS

Endoscopic biliary drainage is a safe and effective measure for the initial control of severe acute cholangitis due to choledocholithiasis and to reduce the mortality associated with the condition.

An interactive computer program for randomization analysis of response curves with facilities for multiple comparisons

An interactive Fortran program, MUCRA, is presented. The program can perform randomization analysis of a completely randomized or randomized-blocks design extended to growth and response curves. A single-step Scheffé-type procedure as well as the Peritz's closed step-down procedure have been implemented which control the familywise type I error-rate. In general, MUCRA is suitable as a computer tool for a distribution-free analysis of variance with repeated measures. The use of MUCRA is demonstrated by analyzing the effects oxprenolol and atenolol have on exercise heart rate. Oxprenolol is a non-selective beta-blocker with moderate intrinsic sympathomimetic activity (ISA), given by the Oros delivery system. Atenolol is a beta 1-selective blocker without ISA. A randomized placebo-controlled crossover design was used to compare the effects of the beta 1-blockers on heart rate during a progressive maximal exercise test on a bicycle ergometer. Application of the Scheffé-type procedure showed that the two drugs significantly (alpha = .05) reduce the heart rate during the exercise test at the three prechosen times (2, 5, and 24 hr) after intake. The reduction from atenolol is more pronounced than from oxprenolol Oros at 2 and 5 hr.

Hangman's fracture in Singapore (1975-1988)

A retrospective study of 33 patients with fracture of the ring of the axis (hangman's fracture) admitted to the Spinal Unit of the Department of Rehabilitation Medicine in the Tan Tock Seng Hospital between 1975 and 1988 was carried out. The aims were to establish the causes, mechanism and outcome of injuries that lead to Hangman's fracture in Singapore. The majority were males (27) and their ages ranged from 16 to 82 with a mean age of 33.7 years. 63.6% (21 cases) were due to road traffic accidents of whom 33% (11 cases) were motorcyclists or pillion riders and 30.3% (10 cases) were drivers or passengers of four wheel vehicles such as cars and vans. Using Effendi et al's classification, we have 21 type I, 11 type II and one type III fractures. Thirteen type I, 6 type II and one type III cases had no neurological deficit on admission. The rest had deficits ranging from tetraparesis to pure bladder dysfunction. After rehabilitation, 28 (84.8%) of them were able to return to gainful employment within a year of their injuries.

Pyuria: index of infection in patients with spinal cord injuries

Little is known about the significance of pyuria in patients with spinal cord injuries. The progress in hospital of 55 such patients was studied. They were divided into 2 groups according to the method of bladder drainage on admission. Group A comprised 43 patients with indwelling catheters. Group B comprised 12 patients who were able to void with tapping, with/without compression and on intermittent catheterisation. The results showed that group A had a mean pyuria level of 185 WBC/HPF on admission. The incidence of urinary tract infection was 4 per patient during hospitalisation and the mean duration of bladder training was 82 days. Group B had a mean pyuria level of 32 WBC/HPF on admission. The incidence of urinary tract infection was 1 per patient during hospitalisation and the mean duration of bladder training was 40 days. The difference between groups A and B for all 3 parameters was statistically significant. These results suggest that patients with spinal cord injuries and indwelling catheters have a higher pyuria level and an increased risk of significant morbidity secondary to urinary tract infection, especially at the pyuria level of 100 WBC/HPF. A low pyuria level of less than or equal to 30 WBC/HPF was associated with a nil or low incidence of bacteriuria and urinary tract infection in our patients.

Exercise performance during captopril and atenolol treatment in hypertensive patients

1. Maximal aerobic exercise capacity, submaximal endurance exercise performance, and exercise haemodynamics have been studied in sixteen patients with mild to moderate essential hypertension during treatment with captopril and atenolol. 2. Administration of atenolol (1 x 100 mg day-1) or captopril (1 x 100 mg day-1) for 6 weeks resulted in similar supine and erect systolic and diastolic blood pressures. Heart rate was significantly lower during atenolol treatment. 3. Exercise heart rate and systolic blood pressure were significantly lower during atenolol than during captopril treatment, exercise diastolic blood pressure (at 100W) did not differ significantly. With atenolol exercise cardiac output was significantly lower and exercise stroke volume significantly higher than with captopril. 4. Maximal work rate, maximal oxygen consumption and maximal heart rate were significantly lower during atenolol than during captopril treatment (respectively 6%, 8% and 25%). Maximal respiratory exchange ratio and lactate concentration did not differ. 5. No statistically significant difference in submaximal endurance time between atenolol and captopril was found. Endurance time was reduced by 19% during atenolol and by 13% during captopril as compared with placebo. No difference in rating of perceived exertion between atenolol and captopril was present. 6. The results indicate that atenolol will reduce blood pressure during exercise more effectively than captopril in patients with hypertension. The limitation of submaximal endurance exercise performance by both agents is of similar magnitude. This may be regarded as an unwanted side effect in certain physically active patients with hypertension.

Hepatic resection for small hepatocellular carcinoma: the Queen Mary Hospital experience

The clinico-pathological features and long-term results of 39 patients with resected small hepatocellular carcinoma (HCC) managed over 19 years in Hong Kong were retrospectively studied (mean diameter +/- standard deviation: 3.6 +/- 1.3 cm). Thirty-one patients were symptomatic and the majority (n = 33) of them had cirrhosis. When compared with 182 patients with large HCC operated within the same period, these patients with small HCC had a significantly higher incidence of spontaneously ruptured lesions (p less than 0.03). Following hepatic resection-major lobectomy (n = 19) and limited hepatic resection (n = 20), operative and hospital deaths occurred in 7.7% and 12.8% of patients, respectively. The size of the lesion had little influence on prognosis. The overall survival at 1, 3, and 5 years was 59%, 28%, and 11%, respectively, which was comparable to patients with large HCC greater than or equal to 5 cm. Further stratification of these 39 patients according to a diameter of greater than 3 cm (n = 22) or less than or equal to 3 cm (n = 17) showed no difference in long-term outcome. When compared with large tumors, frequent encapsulation (p less than 0.04) and less venous permeation (p less than 0.03) were encountered in small HCC. As the extent of hepatectomy had no effect on long-term outcome, limited hepatectomy for patients with small HCC is probably the procedure of choice. A 1 cm macroscopic resection margin is apparently adequate to ensure complete histological disease clearance.

Stroke rehabilitation of elderly patients in Singapore

A retrospective study of 100 elderly stroke patients admitted to a rehabilitation centre in Singapore was done to study the characteristics of the patients and the factors associated with the outcome. The mean age of the patients was 72.7 +/- 5.4 years with an equal sex ratio. There was a predominance of Chinese. Two or more concomitant diseases were present in 43% of the patients with a markedly high prevalence of hypertension. Majority had unilateral motor deficit, and cerebral infarcts were seen in 66% of the scans done. Altogether 79% of the patients improved on their level of self-care in activities of daily living (ADL) while 60% showed improvement in their level of mobility. Patients with good prognosis were those who were assessed to be at least partially independent in ADL prior to rehabilitation and those who showed improvement in the motor power of their affected limbs during rehabilitation. Those with dense hemiplegia at the outset were likely to remain dependent. Age, sex, delay in rehabilitation, duration of rehabilitation, presence of dysphasia and sides of deficit had no bearing on the outcome.

Doxorubicin for unresectable hepatocellular carcinoma. A prospective study on the addition of verapamil

A prospective study was conducted to assess the safety and efficacy of the addition of oral verapamil to intravenous Adriamycin (doxorubicin) for the management of patients with unresectable hepatocellular carcinoma (HCC). All 28 patients studied had histologically verified disease, and cirrhosis was present in 20 of the 21 patients with adequate tissue sampling. The overall median survival was 57 days. Chemotherapy was terminated in seven patients after one course of treatment. Partial response and complete response were noted in four patients (19%) and one patient (4.8%), respectively, among the 21 patients evaluated. Side effects related to the chemotherapy were present in all patients studied. Death from fulminating sepsis occurred in three of the 13 patients with leukopenia. Symptomatic myocardial dysfunction developed in one patient. The addition of verapamil apparently did not potentiate the tumoricidal effect of systemic Adriamycin on HCC but probably did increase its complications.

Use of lower limb prosthesis among elderly amputees

Forty-seven elderly patients (21 males and 26 females) with lower limb amputation, and with prostheses fitted were studied. Their ages ranged from 65 years to 91 years old, with an average of 75.4 years. The three most common contributory causes for amputation were diabetes mellitus, vascular occlusion and carcinoma of the skin. Among the lower limb amputations, below knee amputation was the most common (93.6%). About 30% of the patients developed complications from prostheses, the 3 most common in order of frequency were stump pain, pressure ulcers and stump infection. Male patients tended to do better with prostheses than female patients. More male patients wanted prostheses for mobility, while most female patients cited cosmesis as the reason for wanting a prosthetic leg. More male patients used the prostheses more frequently and this was associated with a higher level of function in terms of self care and mobility. Reasons for non-usage of prosthesis were poor-fitting sockets, floppy stump, stump ulcers and infection. Carers of male amputees tended to cope better than those caring for female amputees. Both the present age of patient, and the age at amputation were found not to be a factor in deciding the frequency of usage of prosthesis, and the outcome of success in rehabilitation of the amputee. Psychological factors played an important role in the outcome of rehabilitation. Eighty-five percent of patients who functioned at a lower level despite a relative lack of serious medical condition cited psychological reasons for their poor performance, among which were age and the 'expected' loss of mobility with amputation.

Doxorubicin for unresectable hepatocellular carcinoma. A prospective study on the addition of verapamil

A prospective study was conducted to assess the safety and efficacy of the addition of oral verapamil to intravenous Adriamycin (doxorubicin) for the management of patients with unresectable hepatocellular carcinoma (HCC). All 28 patients studied had histologically verified disease, and cirrhosis was present in 20 of the 21 patients with adequate tissue sampling. The overall median survival was 57 days. Chemotherapy was terminated in seven patients after one course of treatment. Partial response and complete response were noted in four patients (19%) and one patient (4.8%), respectively, among the 21 patients evaluated. Side effects related to the chemotherapy were present in all patients studied. Death from fulminating sepsis occurred in three of the 13 patients with leukopenia. Symptomatic myocardial dysfunction developed in one patient. The addition of verapamil apparently did not potentiate the tumoricidal effect of systemic Adriamycin on HCC but probably did increase its complications.

Regularity in alcohol distributions: implications for the collective nature of drinking behaviour

The assumption of a one parameter lognormal distribution in the Ledermann theory is relaxed. Implications of only regularity in distributional form for the collective nature of drinking behaviour are considered. It is shown that there must be a so-called point of attraction over which an increase in mean consumption will result in a decrease of percentile point value. The validity of regularity in distributional form and the practical relevance of the Ledermann model is discussed. An example from Dutch data on alcohol consumption among men obtained in 1970 and 1985 illustrates the relevance of an existing point of attraction.

Comparing distributions of alcohol consumption: empirical probability plots

Parametric approaches to the problem of the distribution of alcohol consumption have not been very successful. In this article, it is shown that regulatory in distribution can be studied without making assumptions about a distribution model underlying the data. For this purpose, a method is used with which distributions are compared graphically in so-called probability plots. It appears that, up to a proper linear transformation on a logarithmic scale, a surprisingly large regularity over time can be observed between distributions taken from Dutch samples in 1970, 1981 and 1985. Equally, distributions from male and female sub-samples do not appear to differ up to a linear shift. The finding of a relative equality in distributional form is in accordance with the Ledermann model. However, the difference with the Ledermann's model is that no assumptions about the exact shape of the distributions are being made.

Change of steroidogenic pathways in the ovary of a tropical catfish, Clarias macrocephalus, Gunther, after hCG treatment

Adult female catfish received an im injection of 454 IU hCG in 0.2 ml saline. Sixteen hours later, the ovarian tissue from the hCG-treated or control fish was aerobically incubated in vitro with 4-[14C]progesterone or 17 alpha-hydroxyprogesterone at 30 degrees for 60 min. When progesterone was employed as the substrate, significant production of androstenedione and testosterone was observed in the control group. However, after the hCG injection, a markedly higher amount of 20 beta-hydroxy-4-pregnen-3-one was produced. Furthermore, the androgen production was diminished, and the production of 5 beta-reduced C21 metabolites such as 5 beta-pregnane-3,20-dione and 3 alpha-hydroxy-5 beta-pregnan-20-one was also reduced in the hCG-treated group. From 17 alpha-hydroxyprogesterone as a substrate, considerable amounts of androstenedione and testosterone were obtained as the metabolites in the control group. However, after the hCG treatment, production of 17 alpha, 20 beta-dihydroxy-4-pregnen-3-one (17 alpha, 20 beta-diOHprog) and its 5 beta-reduced metabolite was markedly stimulated, while the androgen production was reduced drastically. By evaluating the yield of each product, it was suggested that the tentatively calculated activity of 17 alpha-hydroxylase and C-17-C-20 lyase was diminished by the hCG treatment and that 20 beta-hydroxysteroid dehydrogenase was activated. It indicates that hCG changed the ovarian steroidogenic pathway from androgen production to formation of 17 alpha, 20 beta-diOHprog, an inducer of germinal vesicle breakdown.